Ann Thorac Surg 2002;74:1008-1010
© 2002 The Society of Thoracic Surgeons
Original article: general thoracic
Induction chemotherapy before operation for multiple endobronchial squamous cell carcinoma of the lung
Kotaro Kameyama, MDa,
Cheng-long Huang, MDa,
Eiichi Hayashi, MDa,
Dage Liu, MDa,
Taku Okamoto, MDa,
Yasumichi Yamamoto, MDa,
Hiroyasu Yokomise, MDa*
a Second Department of Surgery, Kagawa Medical University, Kagawa, Japan
Accepted for publication June 13, 2002.
* Address reprint requests to Dr Yokomise, Kagawa Medical University, 1750-1, Miki-cho, Kita-gun, Kagawa 761-0793, Japan.
e-mail: yokomise{at}kms.ac.jp
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Abstract
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BACKGROUND: Multiple endobronchial squamous cell carcinoma is sometimes difficult to resect due to poor pulmonary function. Although various therapeutic modalities are available, there is no consensus on the effectiveness of chemotherapy in such rare cases. In this study, we evaluated the efficacy of preoperative induction chemotherapy for patients with otherwise unresectable multiple endobronchial squamous cell carcinoma and poor pulmonary function.
METHODS: Six patients with multiple endobronchial squamous cell carcinoma were enrolled in the study. They had a total of 15 foci that were in clinical stage I or II. Due to severe emphysema and poor pulmonary function, all 6 patients were considered unsuitable for complete surgical excision if either bilateral thoracotomy or pneumonectomy was required. The patients received two courses (at 3- to 4-week intervals) of induction chemotherapy, beginning on day 1 with cisplatin (80 mg/m2), vindesine (3 mg/m2), and mitomycin-C (8 mg/m2). After induction chemotherapy, surgical resection was performed on all 6 patients as bilateral thoracotomy and pneumonectomy were avoided due to the effectiveness of induction chemotherapy.
RESULTS: Postoperative pathologic examination revealed a complete response in eight foci. Four nonresected foci have not recurred so far. Although three residual tumors were observed in resected specimens, they all showed moderate responses to chemotherapy. The possible complete response rate is 80%. All patients have survived for 2 to 10 years without apparent recurrence.
CONCLUSIONS: Induction chemotherapy can be added to treatment options for patients with rare multiple endobronchial squamous carcinoma that cannot be resected because of poor pulmonary function.
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Introduction
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Patients with multiple endobronchial squamous cell carcinoma (MEBSCC) often suffer from severe emphysema and poor pulmonary function, usually because of heavy smoking. For this reason, they are unsuitable for primary surgical excision. In such rare cases, as there are no definitive therapeutic modalities, we tried induction preoperative chemotherapy.
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Patients and methods
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Six patients with MEBSCC were enrolled in the study (Table 1).
All patients gave written informed consent and agreed to the protocol. They make up 1.0% of the 604 patients who underwent surgical resection for lung cancer in our hospital from 1983 to 2000. All 6 patients underwent the following studies for staging and surgical tolerance: chest roentgenogram, computed tomographic scans of the chest, abdomen, and brain, fiberoptic bronchoscopy, bone scintigraphy, pulmonary function study, and ultrasonography of the heart. All the patients were male and heavy smokers with squamous cell carcinoma (two foci in 4 patients, three foci in 1 patient, four foci in 1 patient). According to the TNM classification, all 15 foci were evaluated as clinical stage I or II [1]. In all patients, severe emphysema was suspected from the chest computed tomographic scan and pulmonary function study. As complete surgical resection required bilateral thoracotomy or pneumonectomy, they were deemed unsuitable for primary surgical resection. Therefore, the patients received two cycles (at 3- to 4-week intervals) of intravenous systemic induction chemotherapy beginning the first day with cisplatin (80 mg/m2), vindesine (3 mg/m2), and mitomycin-C (8 mg/m2). All 15 foci were reexamined bronchoscopically and histologically 3 weeks after the induction chemotherapy was completed. Two residual tumors were confirmed histologically and seven were suspected bronchoscopically. In the remaining six foci, residual tumors were not observed either histologically or bronchoscopically. As planned, resection of confirmed or suspected tumors was performed 4 weeks after the completion of induction chemotherapy. Operation modes are shown in Table 2.
After operation, and for all patients, a bronchoscopic follow-up was performed every 3 months.
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Table 1. Characteristics of the Patients Undergoing Induction Chemotherapy for Multiple Endobronchial Squamous Cell Carcinoma of the Lung
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Results
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Grade three or higher severe neutropenia was noted in all 6 patients. No other grades three or more severe complications were observed. All patients completed the planned schedule, and there was no chemotherapy-related mortality. After induction chemotherapy, no tumor tissue was revealed in 13 of the 15 foci (Table 2). Pathologically, 8 of 11 (72.7%) resected foci achieved complete remission. Three foci with residual tumor tissue showed a moderate response to induction chemotherapy. Four foci, which had not been resected, have shown no recurrence thus far. All the patients have survived for 2 to 10 years without recurrence.
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Comment
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Multiple endobronchial squamous cell carcinoma of the lung is quite rare [2, 3] and, in our experience, MEBSCC cases were only 1.0% of 604 patients who underwent pulmonary resection for lung cancer. Typically, bilateral thoracotomy or pneumonectomy is recommended for patients with MEBSCC if the patient’s lung function permits the operation [4]. Sometimes, however, patients who smoke heavily suffer from severe emphysema and poor pulmonary function, and although bilateral thoracotomy or pneumonectomy is needed, their lungs cannot tolerate primary surgical resection. After induction chemotherapy, 13 of 15 foci revealed no residual tumor and therefore, bilateral thoracotomy and pneumonectomy were avoided. All subsequent operations were performed without complications.
Today, brachytherapy and photodynamic therapy are available for the treatment of endobronchial lung cancer [5–7]. Both therapies have achieved complete remission in 80% to 90% of early cases. However, these modalities are not available in most facilities and therefore, cannot be considered common therapies. Although tracheobronchoplasty has conventionally been indicated in the treatment of multiple endobronchial lung cancer for the preservation of pulmonary function, there are many cases in which this is impossible [8–10].
In this study, we attempted induction chemotherapy for patients with stage I or II MEBSCC, and this was followed by resection of the foci where there was residual tumor. Induction chemotherapy was originally given to patients with advanced stage III, and recently, it has been applied to stage I and stage II lung cancer [11–14].
Complete remission was confirmed in 8 of 11 resected specimens and the remaining 4 unresected foci have maintained remission for 2 to 10 years. The possible complete remission rate is 80%. All three foci with residual tumor tissue diminished markedly, making operation possible. These results suggest that induction chemotherapy can induce complete remission without surgical resection in some patients and could also enable surgical resection for otherwise unresectable patients. Thus, induction chemotherapy can be added to treatment options for patients with rare multiple endobronchial squamous carcinoma of the lung that cannot be resected because of poor pulmonary function.
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References
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|---|
- International Union Against Cancer. Lung and pleural tumours. In: Sobin LH, Wittekind C, editors. Classification of Malignant Tumours. 5th ed. New York: Wiley-Liss, 1997:91–100
- Auerbach O., Stout A.P., Hammond E.C., Garfinkel L. Multiple primary bronchial carcinomas. Cancer 1967;20:699-705.[Medline]
- Shields T.W. Multiple primary bronchial carcinomas. Ann Thorac Surg 1979;27:1-2.[Medline]
- Korst RJ, Tsuchiya R. Treatment of NSCLC: Surgery. In: Hansen HH, editor. Textbook of Lung Cancer. London: Martin Dunitz, 2000:185–200
- Yokomise H., Nishimura Y., Fukuse T. Long-term remission after brachytherapy with external irradiation for locally advanced lung cancer. Respiration 1998;65:489-491.[Medline]
- Marsiglia H., Baldeyrou P., Lartigau E., et al. High-dose-rate brachytherapy as sole modality for early-stage endobronchial carcinoma. Int J Radiat Oncol Biol Phys 2000;47:665-672.[Medline]
- Okunaka T., Kato H., Konaka C., et al. Photodynamic therapy for multiple primary bronchogenic carcinoma. Cancer 1991;68:253-258.[Medline]
- Maeda M., Nanjo S., Nakamura K., Nakamoto K. Tracheobronchoplasty for lung cancer. Int Surg 1986;71:221-228.[Medline]
- Koike T., Terashima M., Takizawa T., et al. Surgical results for centrally-located early stage lung cancer. Ann Thorac Surg 2000;70:1176-1179.[Abstract/Free Full Text]
- Murakami S., Watanabe Y., Saitoh H., et al. Treatment of multiple primary squamous cell carcinomas of the lung. Ann Thorac Surg 1995;60:964-969.[Abstract/Free Full Text]
- de Boer R.H., Smith I.E., Pastorino U., et al. Pre-operative chemotherapy in early stage resectable non-small-cell lung cancer. A randomized feasibility study justifying a multicentre phase III trial. Br J Cancer 1999;79:1514-1518.[Medline]
- Pisters K.M., Ginsberg R.J., Giroux D.J., et al. Induction chemotherapy before surgery for early-stage lung cancer: a novel approach. Bimodality Lung Oncology Team. J Thorac Cardiovasc Surg 2000;119:429-439.[Abstract/Free Full Text]
- Ukena D. Chemotherapy in stage I + II non-small cell lung cancer. Lung Cancer 2001;33(suppl 1):25-28.
- Depierre A., Westeel V. Overview of the role of neoadjuvant chemotherapy for early stage non-small cell lung cancer. Semin Oncol 2001;28(4 suppl 14):29-36.
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Abstract
Introduction
