(Chest. 2001;120:1595-1598.)
© 2001
American College of Chest Physicians
Operable Non-small Cell Lung Cancer Diagnosed by Transpleural Techniques*
Do They Affect Relapse and Prognosis?
Noriyoshi Sawabata, MD, FCCP;
Hajime Maeda, MD;
Mitsunori Ohta, MD and
Masanobu Hayakawa, MD
*
From the Division of Surgery (Drs. Sawabata and Maeda), Toneyama National Hospital, Toyonaka, Osaka; Division of General Thoracic Surgery (Dr. Ohta), Department of Surgery (E-1), Osaka University Graduate School of Medicine, Osaka; and Division of Surgery (Dr. Hayakawa), Toyonaka City General Hospital, Toyonaka, Japan.
Correspondence to: Noriyoshi Sawabata, MD FCCP, Division of Surgery, Toneyama National Hospital, 5–1-1 Toneyama, Toyonaka, Osaka, Japan; e-mail: nori{at}toneyama.hosp.go.jp
 |
Abstract
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Study objective: We assessed whether transpleural
methods for diagnosing peripheral lung cancer, such as needle
aspiration or tumor excision, affect relapse and prognosis, because
these techniques have potential to spread malignant cells from the
tumor.
Design: A retrospective study.
Setting: National referral hospital.
Patients: We reviewed 239 patients who underwent surgery
between 1990 and 1998 and for whom non-small cell lung cancer (NSCLC)
of < 3 cm in maximum diameter was completely resected. The duration
of postoperative follow-up ranged from 12 to 105 months, with a median
period of 45 months.
Interventions: We defined the
transbronchial method as using a bronchoscope, and the transpleural
method as using needle aspiration cytology or tumor excision.
Dichotomous variables included gender, histologic type of squamous cell
carcinoma or other type of carcinoma, pathologic stage, and whether the
diagnostic method was the transbronchial type only (first-line method)
or the transpleural type (second-line method).
Results: NSCLC was diagnosed in 45 patients by the
transpleural technique and in 194 patients by the transbronchial
technique. There were no significant statistical differences in
age of patients, gender, histologic type, pathologic stage, and tumor
size. There were 42 relapses, 7 in the transpleural technique group and
35 in the transbronchial technique group (p = 0.90). Of the 7
patients in the transpleural group, there were 4 distant metastasis and
3 local relapses; of the 35 patients in the transbronchial group, there
were 20 distant metastasis and 15 local relapses (p = 0.99). Pleural
carcinomatosis occurred in none of the 45 patients in the transpleural
group and in 1 case (0.5%) in the 194 patients in the transbronchial
group (p = 0.99). Patients in the transpleural group had a
statistically better 5-year survival rate than patients in the
transbronchial group (79.4% vs 60.3%, p = 0.04). This is also
confirmed as an independent prognostic factor in a multivariate
analysis.
Conclusions Transpleural methods seem to be
an advisable way to diagnose operable lung cancer that is difficult to
diagnose using bronchoscopy, because these methods did not affect
relapse and prognosis in the patients in our study.
Key Words: excision • needle aspiration cytology • non-small cell lung cancer
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Introduction
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The
transbronchial approach using a bronchoscope is one of the most common
methods of diagnosing lung cancer. Some peripheral lung cancers, which
cannot be diagnosed employing a bronchoscope, are diagnosed by a
transpleural method such as needle aspiration cytology1
2
3
or tumor excision.4
5
These techniques have the potential
to spread malignant cells from the tumor. Chest wall implantation is a
serious cause of morbidity.6
7
8
Besides, dissemination of
lung cancer cells by needle biopsy of the lung9
and
pleural carcinomatosis following tumor excision using video-assisted
thoracic surgery (VATS)6
10
have been reported. By
contrast, it has been reported11
that lung adenocarcinoma
diagnosed by excision more frequently shows a smaller degree of central
fibrosis on histologic examination, and may have good prognosis. There
are ambivalent opinions regarding the prognosis of non-small cell lung
cancer (NSCLC) diagnosed by the transpleural method. In order to assess
whether or not transpleural methods for diagnosing peripheral lung
cancer affect relapse and prognosis, we conducted a retrospective study
by classifying patients with NSCLC into two groups: patients with NSCLC
diagnosed by the transbronchial method and patients with NSCLC
diagnosed by the transpleural methods.
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Materials and Methods
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We chose patients who underwent surgery between 1990 and 1998
and for whom NSCLC of < 3 cm in maximum diameter was completely
resected at Toneyama National Hospital, in Osaka, Japan. Lung cancers
diagnosed by needle aspiration cytology or tumor excision were all
< 3 cm in maximum diameter; therefore, we selected lung cancers < 3
cm in maximum diameter in the transbronchial group. During the period,
a total of 521 patients underwent surgery for lung cancer and there
were 239 patients who matched the selection criteria. Survival and
relapse data were obtained by reviewing the hospital records and
contacting patients or their families. All surviving patients were
contacted by March 2000. The duration of postoperative follow-up ranged
from 12 to 105 months, with a median period of 45 months. The survival
duration was measured from the date of surgery until the date of
follow-up contact or death.
We routinely undertook bronchoscopy (transbronchial method) for a lung
lesion that was suspicious of being lung cancer even if it was tiny and
existed peripherally. When a lesion could not be diagnosed employing
bronchoscopy, we undertook percutaneous needle aspiration cytology when
the lesion was located peripherally. We used tumor excision for lesions
that had not been diagnosed by percutaneous needle aspiration biopsy or
were located at difficult regions for percutaneous needle aspiration
technique. When the tumor was diagnosed as NSCLC, residual surgery was
undertaken in the same surgical procedure. We used a single 22-gauge
needle for needle aspiration cytology. We routinely examined the
patients who had undergone surgery for lung cancer every 3 months for
at least 5 years. At every attendance, chest radiography and blood test
analyses were undertaken. Pleural carcinomatosis was defined when chest
radiography revealed a pleural effusion and malignant cells were
detected in it. When symptoms occurred, which were supposed to be
derived from cancer relapse, further examinations were
undertaken.Dichotomous variables included gender, histologic type of
squamous cell carcinoma or other types of lung cancer, pathologic
stage, and whether the diagnostic method was by means of transpleural
techniques or other techniques.
Potential prognostic factors in predicting the long-term survival of
the 239 patients were evaluated by a Cox proportional-hazard model.
Survival curves were obtained according to the Kaplan-Meier method.
Comparison of survival curves was carried out using a log-rank test.
Statistical significance was calculated using the Student’s
t test and the 
2 test. These
calculations were conducted with StatView 4.5 (Abacus Concepts;
Berkeley, CA).
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Results
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Of the 239 patients, there were 156 men and 83 women aged 31 to 81
years, with a median age of 61 years. Histologic diagnoses included 157
cases of adenocarcinoma, 60 cases of squamous cell carcinoma, 11 cases
of carcinoid, 10 cases of large cell carcinoma, and 1 case of
adenosquamous cell carcinoma. Pathologic stages included 148 cases of
stage IA, 20 cases of stage IB, 24 cases of stage IIA, 6 cases of stage
IIB, 31 cases of stage IIIA, 1 case of stage IIIB, and 9 cases of stage
IV. One hundred ninety-four lesions were diagnosed using bronchoscopy,
and 45 lesions were diagnosed by a transpleural method: fine needle
aspiration (n = 22) and tumor excision (n = 23). Of the 23 patients
who underwent tumor excision, 18 patients underwent VATS and 5 patients
underwent thoracotomy. Tumor excision was undertaken for tumor
diagnosis. When the tumor was diagnosed to be NSCLC, residual surgery
was undertaken. In the transbronchial group, there were 102 tumors in
the right lung (63 upper lobe, 5 middle lobe, and 34 lower lobe) and 92
tumors in the left lung (52 upper lobe and 40 lower lobe). Of the 194
tumors in the transbronchial group, the minimum distance from the
pleura to the tumor was < 1 cm in 85% of cases (n = 167). By
contrast, in the transpleural group, there were 23 cases in the right
lung (15 upper lobe, 2 middle lobe, and 6 lower lobe) and 22 in the
left lung (12 upper lobe and 10 lower lobe). Ninety-five percent of the
tumors (43 of 45 tumors) in the transpleural group were located within
a minimum of 1 cm from the pleura. There was not a statistically
significant difference in the location of tumors between the two groups
(p = 0.1). Regarding operations, there were 206 lobectomies, 5 sleeve
lobectomies, 10 lobectomies with partial resection, 12 bilobectomies,
and 6 pneumonectomies.
A comparison of backgrounds between patients in the transpleural group
and in the transbronchial group is shown in Table 1
. There were no statistical difference in age of patients, gender,
histologic type (squamous cell carcinoma or other type of lung cancer),
pathologic stage, tumor size, pathologic node status, and pathologic
tumor status.
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Table 1.. Comparison of Backgrounds Between Patients in the
Transpleural Group and Patients in the Transbronchial
Group*
|
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There were 42 relapses: 7 in the transpleural group and 35 in the
transbronchial group (p = 0.90). We defined local relapse
as relapse that occurred in the ipsilateral thoracic cage, and
pleural carcinomatosis as malignant pleural effusion with or
without pleural dissemination. Of the seven patients in the
transpleural group, there were four distant metastases and three local
relapses. Of the 35 patients in the transbronchial group, there were 20
distant metastases and 15 local relapses (p = 0.99). Pleural
carcinomatosis occurred in no cases (0%) in the 45 patients in the
transpleural group and one case (0.5%) in the 194 patients in the
transbronchial group (p = 0.99; Table 2
).
Results of the univariable analysis for survival are shown in Table 3
. Patients in the transpleural group had a statistically better
prognosis than patients in the transbronchial group (Fig 1 ). This is also confirmed in a multivariate analysis as shown in Table 4
.
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Figure 1.. Survival curve of patients in the
transpleural method group and patients in the transbronchial method
group. Patients in the transpleural method group had a significantly
better survival rate than patients in the transbronchial method group
(p = 0.04).
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Discussion
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Transpleural needle aspiration cytology and tumor excision have
the potential to spread malignant cells from the tumor when these
techniques are applied for diagnosis of malignant
lesions.12
13
Malignant cells are identified on the pleura
in 60% of cases following fine-needle aspiration
cytology6
and on the excised margin in 40% of cases
following excision for malignant lesions, even where there has been a
sufficient distance of 1 cm.7
If these malignant cells
grow and lead to relapse, these techniques have to be employed
prudently. Chest wall implantation is a possible danger. During tumor
excision using VATS, chest wall implantation might be avoided by
employing a protective container.10
In needle aspiration
cytology, the fine single 22-gauge needle may be more beneficial in
preventing chest wall implantation than a needle device that can
harvest tumor tissue for histologic diagnosis. Fortunately, we have not
experienced chest wall implantation in patients in this study with
NSCLC diagnosed by transpleural techniques.
It has been reported14
that there was no significant
correlation between preoperative transthoracic needle biopsy and
malignant pleural lavage cytology, and pleural carcinomatosis is not
common in patients showing malignant positive pleural lavage cytologic
findings. In addition, in patients who underwent pleuroperitoneal shunt
for the treatment of malignant pleural effusion, abdominal
carcinomatosis has not been reported.15
16
17
This evidence
may show that contaminated NSCLC cells have a low potential to grow in
normal pleural space or peritoneal spaces. However, cases of pleural
carcinomatosis following transthoracic needle aspiration cytology or
tumor excision using VATS have been reported.8
9
10
Peripheral lung tumors may be more often diagnosed by the transpleural
method. Tumors that were not diagnosed by bronchoscopy but by excision
often show less frequent invasion beyond the pleural surface, and a
lower grade of in-tumor central fibrosis (a malignancy factor and the
extent of bronchi or vessel involvement with tumors).11
Central fibrosis, which is a predictor for extensive bronchial
involvement, has been reported18
19
to be a poor
prognostic factor in small-size adenocarcinoma < 3 cm in maximum
diameter. The more bronchi that are involved, the more frequently a
tumor is diagnosed to be malignant by bronchoscopy and the prognosis is
thought to be poor. It could be that patients with lung cancers
diagnosed by a transpleural technique following an unsuccessful
procedure of bronchoscopy may have a better prognosis than patients
with lung cancers diagnosed by bronchoscopy.
In this study, there was no significant difference in relapse rate,
type of relapse (distant metastasis/local relapse), and frequency of
pleural carcinomatosis (the result of local tumor spread) between the
transpleural group and the transbronchial group. On the other hand,
patients in the transpleural group had a superior prognosis compared to
patients in the transbronchial group in both single and multivariate
analysis. From these points of view, the transpleural technique
is an acceptable method of diagnosing NSCLC, which is difficult to
diagnose using bronchoscopy. Lung cancer has to be diagnosed as early
as possible in order to maximize the chance of recovery. Patients who
might have lung cancer should undergo a transpleural technique when
bronchoscopic examination has failed to diagnose a lesion.
In conclusion, transpleural techniques are advisable methods for
diagnosing operable NSCLC < 3 cm in maximum diameter, which is
difficult to diagnose using bronchoscopy, because the results of this
study indicate that these techniques do not affect relapse and
prognosis.
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Footnotes
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Abbreviations: NSCLC = non-small cell
lung cancer; VATS = video-assisted thoracic surgery
Received for publication September 25, 2000.
Accepted for publication June 4, 2001.
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TOP
Abstract
Introduction
