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Ann Thorac Surg 1997;63:324-326
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Surgical Results and Prognostic Factors in Early Non–Small Cell Lung Cancer

Thoracic Surgery Service, University Hospital "La Fe," Valencia, Spain

Accepted for publication August 27, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. We attempted to clarify the prognostic value of tumor size (maximum, 3 cm), the evidence of invasion proximal to a lobar bronchus at least 2 cm distal to the carina, and the absence or presence of visceral pleura invasion in patients with completely resected non–small cell lung carcinoma without lymph node invasion or satellite lesions (T1 N0 M0, T2 N0 M0).

Methods. The study included 158 patients. Four patients were excluded due to postoperative mortality (2.5%). The variables selected for the survival study were sex, age, symptoms presence or absence, bronchial invasion level (evidence or not of invasion proximal to a lobar bronchus at least 2 cm distal to the carina), pulmonary location, pneumonectomy or lesser resection, cell type, squamous or nonsquamous, tumor size, invasion or not of the visceral pleura, and T1 or T2 status.

Results. The overall survival rate in this series was 74% at 5 years and 60% at 10 years. Only the tumor size had a significant influence on survival (p = 0.0092). Patients with a tumor less than 2 cm in diameter did better (p = 0.0023).

Conclusions. These observations suggest that it will be necessary to further research in clarifying the prognostic value of the bronchial invasion level and of the degree of the visceral pleura invasion and its implications when classifying a tumor as T1 or T2.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
A recent review of surgical series [1] has shown that stage I of the proposed International Staging System [2] is not made up of a homogeneous group of patients. As a result, the survival of the T1 N0 M0 subgroup is significantly greater than that of T2 N0 M0. However, the problem is more complex, as there are differences not only between subgroups but also within the same subgroups. This would explain why, depending on the series revised, there is an important variation in the 5-year survival periods of the T1 N0 M0 subgroups (from 68.5% to 83%).

It is surprising the lack of studies devoted to evaluating the factors that determine whether a tumor will be classified as T1. Although tumor size is considered as an important prognostic factor, it is not clear whether other factors such as the evidence of invasion proximal to a lobar bronchus at least 2 cm distal to the carina or the invasion of the visceral pleura are determinants in the classification of a 3-cm tumor as T1 or T2.

The aim of this article is to analyze the prognostic value of tumor size (maximum, 3 cm) and bronchial invasion level as well as the presence or absence of visceral pleura invasion in patients with T1 N0 M0 and T2 N0 M0 tumors.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
From 1969 to 1993, a total of 158 non–small cell lung cancers with a maximum diameter of 3 cm and without lymph node invasion were completely resected in the Thoracic Surgery Service of the Hospital "La Fe" in Valencia. Postoperative mortality occurred in 4 patients (2.5%), and as such they were excluded from our study. The variables selected for the survival study were sex, age, symptoms (presence or absence), bronchial invasion level (evidence of invasion proximal to a lobar bronchus at least 2 cm distal to the carina), pulmonary location, pneumonectomy or lesser resection (anything less than pneumonectomy), cell type, squamous or nonsquamous, tumor size, invasion of the visceral pleura, and T1 or T2 status.

The Kaplan-Meier method [3] was used to estimate the survival probability. The different curves were statistically compared using the Tarone-Ware test [4]. The data were considered significant when the p value did not exceed 0.05. All the significant variables from this univariate method were then used in a multivariate analysis through the method of regression of the proportional risk for survival data developed by Cox [5]. The statistical study was accomplished with the 1L and 2L programs from the BMDP statistical package [6]. The observation date was December 31, 1994.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
One hundred forty-three patients were men (93%) and only 11 (7%) were women. The mean age was 60.7 ± 7.9 years (range, 36 to 77 years). The neoplasia was exclusively a radiologic finding in 61 patients (40%), whereas 93 (60%) presented clinical symptoms. There was no evidence of invasion proximal to a lobar bronchus in 128 patients (83%), and the tumor involved the main bronchus, 2 cm or more distal to the carina, in 26 patients (17%). The lesion affected the right and left lung in 84 (55%) and 70 (45%) patients, respectively. Lesser resection was achieved in 124 patients (81%) and pneumonectomy was necessary in 30 (19%). When a lesser resection was used, segmentectomy was accomplished in 9 patients, lobectomy in 103, and bilobectomy in 12. The cell type was considered epidermoid in 98 tumors (64%), adenocarcinoma in 44 (28%), and large cells carcinoma in 12 (8%). The mean diameter of the tumor was 2.37 ± 0.65 cm (range, 0.1 to 3 cm). Tumor size was between 0.1 and 1 cm in 10 patients, 1.1 and 2 cm in 51, and 2.1 and 3 cm in 94 patients. The visceral pleura was affected in 19 of the 154 patients. One hundred nine tumors were classified as T1 N0 M0 (71%) and 45 (29%) as T2 N0 M0. The overall survival rate of the series was 74 ± 3.9% at 5 years and 60 ± 5.3% at 10 years (Fig 1).

View larger version (10K): [in this window] [in a new window]   Fig 1. . Overall survival rate.

View larger version (14K): [in this window] [in a new window]   Fig 2. . Survival by tumor size.

View larger version (13K): [in this window] [in a new window]   Fig 3. . Survival by tumor size (cutoff = 2 cm).

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Tumoral size has been evaluated as a prognostic factor in stage I non–small cell lung cancer [7–9]. However, many survival studies of tumoral lesions classified as T1 N0 M0 do not make any reference to the diameter of these tumors as a prognostic factor [10–12]. Recently, some articles have concluded that tumors of 2 cm or less have a significantly better prognosis than tumors with a size between 2.1 and 3 cm [13, 14]. Read and co-workers [14], for instance, suggests that the T1 N0 M0 category is not uniform and they argue that a new category in this group should be created (T1/2) [13]. We agree with this proposal, as in our series it was the only factor correlated with survival.

Another variable that determines the T1 or T2 status in tumors with a maximum diameter of 3 cm is the bronchial invasion level. When there is no proximal invasion to a lobar bronchus the tumor is classified as T1. On the contrary, when the lesion involves the main bronchus, 2 cm or more distal to the carina, it is considered as T2, suggesting a worse prognosis. In our series, the bronchial invasion level did not influence survival. Naruke and co-workers [15] have identified a group of patients who had tumors confined to the bronchial mucosa yet resided within 2 cm of the carina and that had no associated lymph node metastases. This group of patients, theoretically with a worse prognosis, had a 5-year survival rate of 80%. Watanabe and co-workers [16] also identified an excellent survival rate in patients with such lesions. Accordingly, these lesions have been classified as T1 N0 by the International Staging System.

The T2 classification includes tumors of any size with invasion of the visceral pleura. Harpole and co-workers [7] and Ichinose and co-workers [8] have shown a poor prognosis in patients with stage I tumors associated with visceral pleura invasion. Martini and co-workers [9] do not agree with the conclusions of Harpole and Ichinose and their colleagues, and suggest that the visceral pleural involvement does not influence, but it is a contributing adverse factor in patients with large tumors. In our study, the visceral pleura invasion determined a smaller survival rate, although it was not significant.

In conclusion, the results obtained in this work highlight that the size of the tumor in patients affected by non–small cell lung cancer with a maximum diameter of 3 cm and without lymph node invasion or satellite lesions correlates with survival rate; therefore, we support the reassessment of the T1 N0 group. It is also necessary to evaluate the prognostic value of the bronchial invasion level and the degree of the visceral pleura invasion and its implications when classifying a tumor as T1 or T2, as we have not found significant survival differences between these groups. However, because of the limited number of patients included in our study, it will be necessary to conduct further research.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Padilla, Servicio de Cirugía Torácica, Hospital Universitario "La Fe," Avda de Campanar 21, 46009 Valencia, Spain.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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