Long-term survivors after resection of lung carcinoma

Long-term survivors after resection of lung carcinoma As of January, 1976, 257 patients with lung cancer who were entered into one of four surgical adjuvant chemotherapy lung trials prior to January, 1966, had survived 10 years. One hundred twenty-five of these 257 patients had been in the program for 15 years, and 69 patients had survived. One hundred thirty-three lobectomies, 120 pneumonectomies, and four lesser resections were the procedures performed. The cell type was squamous cell in 185 patients, adenocarcinoma in 24, other cell types in 47, and unknown in one. Lymph node metastases at the time of resection were absent in 185 of the patients, present in either the lobar or hilar nodes in 59, and present in the mediastinal nodes in 11, the status was unknown in two. Ninety-seven patients have died since the tenth year anniversary. The major causes of death were cardiovascular and pulmonary diseases and second primary carcinomas. The latter were the cause of death in 25 patients. Of the 257 patients, 51 (19.8 percent) had a second primary tumor. In 25 patients, a second lung tumor was discovered—in seven patients prior to the eleventh postoperative year and in 18 patients after the tenth year. Six of these patients had a new primary in another organ system as well. Nine patients underwent definitive surgical treatment of the new lung lesion. In 26 additional patients, a second or even a third new primary was discovered in another organ system. Over one half of the patients with these tumors could be treated definitively. Because of the high risk of the occurrence of a second primary tumor in the long-term survivors, frequent and life-long observation is indicated.

Thomas W. Shields, M . D . , * Chicago, III., Edward W. Humphrey, M.D.,** Minneapolis, Minn., George A. Higgins, Jr., M.D.*** (by invitation), and Robert J. Keehn, M.S.**** (by invitation), Washington, D. C.

A he Veterans Administration Surgical Adjuvant Study Groupt has conducted a series of prospective clinical trials during the past two decades to evaluate Read at the Fifty-eighth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., May 8, 9, and 10, 1978. Address for reprints: Thomas W. Shields, M.D., Department of Surgery, Veterans Administration Lakeside Hospital, 333 East Huron Street, Chicago, 111. 60611. *Professor of Surgery, Northwestern University Medical School; Chief, Surgical Service, Veterans Administration Lakeside Hospital, Chicago, 111. **Professor of Surgery, University of Minnesota School of Medicine; Chief, Surgical Service, Veterans Administration Hospital, Minneapolis, Minn. ***Professor of Surgery, Georgetown University Medical School; Clinical Professor of Surgery, George Washington University Medical School; Chief, Surgical Service, Veterans Administration Hospital, Washington, D. C. ****Project Statistician, Medical Follow-up Agency, National Academy of Science-National Research Council, Washington, D. C. tFor listing of members of the Veterans Administration Surgical Adjuvant Group, see end of article.

the use of various adjuvant chemotherapeutic regimens after the surgical resection of lung cancer as well as one trial to evaluate the use of preoperative irradiation. In each trial only men with bronchial carcinoma were admitted. Although the adjuvant therapy was different in each trial, the criteria for accepting a patient into the studies remained basically the same, with minor exceptions as to the extent of the disease and the time of randomization in reference to the operation. After discharge from the hospital, the patients in each trial were followed at 3 month intervals for the first 3 to 5 years; thereafter, most patients were seen on a semiannual or annual basis. Some patients were lost to follow-up for varying periods of time, but as the result of the Veterans Administration records system* all deaths are eventually reported. In the completed adjuvant drug trials, long-term survival has been essentially the same for those patients who received the therapeutic regimen as for those who did not. 1, 2 In the preoperative radiation therapy trial, *BIRLS (Beneficiary Identification and Records Location Subsystem).

439

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4 4 0 Shields et al.

Table I. Ten-year survivors: Cell type and node involvement Undiffer-

Adenocarcinoma

Sq uamous

entiated

NO Nl N2 Unknown

130 48 6 1

36 6 4 1

18 5 1

1

Totals

185

47

24

1

Unknown

survival was no different in the total treatment or total control groups. However, preoperative radiation therapy was found to be harmful in those patients who underwent subsequent resection as compared to those who underwent resection without such therapy.3 The 5 and 10 year postoperative survival rates, approximately 25 and 15 percent, respectively, varied slightly in each of the adjuvant therapeutic trials, but not to a degree which would preclude combining the treated and control groups in this report. As of January, 1976, 257 patients who had been entered into one of the trials* prior to January, 1966, had survived 10 years. One hundred twenty-five of the 257 patients had been in the program for 15 years, and 69 of them were 15 year survivors. The age at the time of randomization of the 257 who had survived 10 years ranged from 36 to 79 years. The greatest number of patients were in the seventh decade of life but the average age was 56 years. The operations performed were pneumonectomy in 120 patients, lobectomy in 133, and lesser resections in the remaining four patients. The cell type was squamous cell carcinoma in 185 patients, adenocarcinoma in 24, and undifferentiated cell carcinoma in 47; the cell type was not recorded in one patient. Examination of the resected specimens revealed metastases to the lymph nodes to be absent in 185 of the patients, present in either the lobar or hilar nodes in 59, and present in the mediastinal nodes in 11; the status of lymph node involvement was unknown in two patients. Cell type and incidence of lymph node involvement are shown in Table I. In the subset of the 69 patients who survived 15 years, the age at randomization ranged from 36 to 79 years. The majority of patients were in the fifth decade of life but the average age was 52 years. Forty patients had undergone a pneumonectomy and 29 patients a lobectomy. The cell type was squamous cell carcinoma in 50 patients, undifferentiated cell type in 14, and */, HN2, full dose. 2, HN2, reduced dose. 3, Series X and Compound 62-63 (nonchemotherapeutic agents). 4, Cytoxan. 5, Preoperative radiation therapy trial.

adenocarcinoma in the remaining five patients. Metastatic involvement of lymph nodes was absent in 45 patients, present in the lobar or hilar nodes in 20, present in the mediastinal nodes in three, and unknown in the remaining patient. As of June, 1977, 160 of the 257 patients who were 10 year survivors were alive. One hundred twentyseven of the living patients (79 percent) had been seen recently by their physicians prior to the review. Ninety-eight of these patients were considered to be in essentially good health. Twenty-nine patients were considered to be ill. The majority of these patients had disabling pulmonary or cardiac disease, and several patients had an unresectable carcinoma either of the lung or of another organ system. In 33 patients who were alive, recent health status was unknown at the time of review. In the subset of 69 patients who survived beyond the fifteenth postoperative year, 61 patients were alive and eight patients had died at the time of review. Thirty-five patients were considered to be alive and well, 16 patients were considered chronically ill, and the health status was unknown in the other 10 patients. The quality of life of any given patient was difficult to discern and obviously varied from time to time. Over-all, it appeared to be dependent upon the extent of the original operative procedure, the age at operation, the development of other organ disease, and whether or not the patient continued to smoke. Ninety-seven patients, eight of whom had survived 15 years or longer, had died since their tenth anniversary. The causes of death were determined from the autopsy findings in 21 patients and from the clinical record and death certificate in 71, in five patients, despite a death certificate or in the absence of-one, the cause of death could not be discerned with any reasonable degree of accuracy. The major causes of death, although many patients had multiple organ systems involved, were cardiopulmonary disease in 52 patients, carcinoma in 25 patients, cerebrovascular disease in nine, and massive gastrointestinal hemorrhage in five. One patient committed suicide. Of the patients who had died as the direct result of cancer, 16 patients had what was considered a second primary lung tumor and nine had a fatal second primary tumor in another organ system. The factors considered in judging whether or not a newly discovered pulmonary lesion was a second primary were its cell type, the anatomic location, the time interval since the initial lesion, and the presence or absence of associated metastatic disease. Of the 257 patients who were 10 year survivors, 51

Volume 76 Number 4 October, 1978

(19.8 percent) are known to have had one or more new cancers since resection of the initial lung tumor. Twenty-five patients had what was considered to be a second primary in the lung, although the possibility of the new lung lesion being a recurrence could not be excluded in every patient. Initially, 17 of these patients had undergone a lobectomy, seven a pneumonectomy, and one patient a segmentectomy. The second lesion was discovered prior to the sixth postoperative year in one patient, after the fifth year and before the eleventh year in six, after the tenth year and before the sixteenth year in 15, and after the fifteenth year in the remaining three patients. Nine patients underwent definitive surgical treatment of the second lung tumor. There were six lobectomies with two postoperative deaths, and there were two completion pneumonectomies and one wedge resection with no postoperative deaths. One resection was performed prior to the sixth year, five after the fifth year, and the remaining three after the tenth year (the two postoperative deaths were in this group). In two of the surgically treated patients, either a third primary carcinoma of the lung developed or the third pulmonary lesion represented a late metastasis. A third pulmonary lesion was also found at autopsy in one of the patients who died in the postoperative period. In addition, in six of these 25 patients, a second primary tumor either was present or subsequently developed in another organ system. Thirty-six second or third primary tumors of organ systems other than the lung were recorded in the 257 patients (Table II). These occurred in 36 patients including the aforementioned six patients who also had a second lung tumor. The most common sites in which the tumors occurred were the bladder, the colon, and the orolaryngeal area. Slightly more than one half of the patients with these tumors underwent definitive treatment for cure, whereas the remainder received only palliative or symptomatic care. Discussion The occurrence of a second primary tumor is not uncommon in long-term survivors of a successful resection of a primary carcinoma of the lung. One half of these new tumors occur in a different organ system. The majority of them develop in the orolaryngeal area or in the genitourinary system and may be related to cigarette smoking. The other half occur in the remaining lung. Many of these patients, if not most, have continued to smoke after their initial operation. In most instances, it is difficult if not impossible to determine whether or not the second lung lesion represents a new primary or is just a late metastasis of the

Lung carcinoma

441

Table II. Ten-year survivors: Sites of second primary tumors other than lung Site

No.

Bladder Large bowel Larynx Oropharynx Prostate Penis Meninges Testicle Liver Salivary gland Kidney Thyroid Stomach

8 6 5 4 3 2 2 1 1 1 1 1 1

Total

36

initial tumor. The criteria of Warren and Gates4 are very explicit as to which lesions represent a new primary in patients who have had a previous cancer. However, most often these criteria cannot be met in patients in whom the initial primary was in the lung and the second lesion also occurred in the lung. The most definitive guideline is the presence of different histologic patterns in the two tumors, but unfortunately this criterion is the one least often met. Another suggested criterion,5' 6 a long time interval between the discovery of the first and second lesions, is reasonable and is the one most often satisfied in long-term survivors. However, this in itself does not rule out the possiblity of a late metastasis. In reality, the exact differentiation between the two possibilities makes little or no practical difference clinically. In the long-term survivor, a newly discovered pulmonary lesion should be clinically considered to be a second primary tumor and managed as such. When the new pulmonary lesion is confined to the lung, appropriate definitive therapy is indicated. In many patients, however, the new lesion has spread beyond the confines of the remaining lung at the time of discovery, the patient having returned to the physician or surgeon only because of symptoms referable to the dissemination of the new tumor. When there is evidence of regional or distant metastatic spread, palliation is the only logical goal. Unfortunately, even when the lesion is confined to the lung, surgical intervention is frequently precluded either because of the general medical condition of the patient or because the surgical procedure required to eradicate the disease would leave insufficient lung volume to sustain life. Although infrequently reported, 5-7 second primaries were observed to have developed in seven patients who

4 4 2 Shields et al.

had undergone a previous pneumonectomy in this series. In such patients, a wedge resection or segmentectomy may be contemplated but a lobectomy is contraindicated. In those patients with a previous lobectomy or lesser procedure, the surgical options for removal are greater. Numerous successful resections of second lung primaries have been reported by Abbey Smith8, 9 and others.5-6- 10 When the entire population with bronchial carcinoma is considered, the problem of a second primary lung tumor is a minuscule one; only 0.5 percent of the men with the diagnosis will have a second primary lung tumor diagnosed before death. In the patients subjected to resection the risk is increased to approximately 2 percent, and in the long-term survivors the risk is almost 10 percent. Thus one man in 10 still living 10 years after the diagnosis of a carcinoma of the lung will have had a second lung primary diagnosed before his eventual death. It is in these patients that the problem is a significant one. The solution is not easy but may be approached by several avenues that have been suggested numerous times. First, the initial pulmonary resection should be as conservative of lung tissue as is commensurate with the extent of the disease.11 A lobectomy is the preferred procedure. When applicable, a bronchoplastic procedure 12-14 or even a segmentectomy15,16 may be used. However, a pneumonectomy remains a satisfactory procedure when the entire local disease process can be eradicated by the resection. It should not be withheld because of the cell type of the tumor, as recently suggested by Kirsh and his associates.17 Involvement of mediastinal nodes, particularly when the metastatic disease is intracapsular, does not always contraindicate resection, because in this study as in other reports 18-22 such involvement does not always preclude long-term survival. Second, the patients should be counseled to cease smoking, since smoking may have a causative relationship not only to the second lung tumor but also to tumors in other organ systems. Third, a long-term survivor should not be discharged from periodic examinations arbitrarily at the fifth or subsequent years simply because he is doing well. Instead, he should be seen at least three or four times a year as long as he is alive. Fourth, at the periodic visits, not only should an interval history be taken and an examination be done, but standard posteroanterior and lateral roentgenograms of the chest should be obtained. When available, cytologic examinations of the sputum should also be done. Whether or not yearly studies with the fiberoptic bronchoscope should be carried out cannot be answered. In

The Journal of Thoracic and Cardiovascular Surgery

all likelihood this examination would yield little as a routine, but probably would be most rewarding in those patients who have signs or symptoms, an abnormal roentgenographic shadow, or abnormal results from cytologic studies of sputum. By such steps, particularly by stopping smoking, a second primary tumor might be prevented; however, if one did develop, its early detection might permit successful definitive treatment. REFERENCES 1 Shields TW, Humphrey EW, Keehn RJ: Adjuvant cancer chemotherapy after resection of carcinoma of the lung. Cancer 40:2057-2063, 1977 2 Shields TW, Robinette D, Keehn RJ: Bronchial carcinoma treated by adjuvant cancer chemotherapy. Arch Surg 109:329-333, 1974 3 Shields TW: Preoperative radiation therapy for carcinoma of the lung. Cancer 30:1388-1394, 1972 4 Warren S, Gates O: Multiple primary malignant tumors. A survey of the literature and a statistical study. Am J Cancer 16:1358-1414, 1932 5 Martini N, Melamed MR: Multiple primary cancers. J THORAC CARDIOVASC SURG 70:606-612, 1975 6 Razzuk MA, Pockey M, Urschel HC Jr, Paulson DL: Dual primary bronchogenic carcinoma. Ann Thorac Surg 17:425-433, 1974 7 Brock R: Thoracic surgery and the long-term results of operation for bronchial carcinoma. Ann R Coll Surg Engl 35:195-210, 1964 8 Abbey Smith R: Development and treatment of fresh lung carcinoma after successful lobectomy. Thorax 21:1-20, 1966 9 Abbey Smith R, Nigam BK, Thompson JM: Second primary lung carcinoma. Thorax 31:507-516, 1976 10 Neptune WB, Woods FM, Overhold RH: Reoperation for bronchogenic carcinoma. J THORAC CARDIOVASC SURG 52:342-350, 1966 11 Price Thomas C: Conservative and extensive resection for carcinoma of the lung. Ann R Coll Surg Engl 24:345365, 1969 12 Jensik RJ, Farber LP, Milloy FJ, Amato JJ: Sleeve lobectomy for carcinoma. A ten-year experience. J THORAC CARDIOVASC SURG 64:400-412, 1972

13 Paulson DL, Urschel HC Jr, McNamara JJ, Shaw RR: Bronchoplastic procedures for bronchogenic carcinoma. J THORAC CARDIOVASC SURG 59:38-48, 1970

14 Rees GM, Paneth M: Lobectomy with sleeve resection in the treatment of bronchial tumours. Thorax 25:160-164, 1970 15 Jensik RJ, Farber LP, Milloy FJ, Monson DO: Segmental resection for lung cancer. Afifteen-yearexperience. J THORAC CARDIOVASC SURG 66:563-572, 1973 16 Shields TW, Higgins GA Jr: Minimal pulmonary resection. Arch Surg 108:420-422, 1974 17 Kirsh MM, Rotman H, Argenta L, Bove E, Cimmino V,

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18 19 20

21

22

Lung carcinoma

Tashian J, Ferguson P, Sloan H: Carcinoma of the lung. Results of treatment over ten years. Ann Thorac Surg 21:371-377, 1976 Abbey Smith R: The importance of mediastinal lymph node invasion by pulmonary carcinoma in selection of patients for resection. Ann Thorac Surg 25:5-11, 1978 Brock R: Long survival after operation for cancer of the lung. BrJ Surg 62:1-5, 1975 Kirsh MM, Kahn DR, Gago O, Lampe I, Fayos JV, Prior M, Moores WY, Haight C, Sloan H: Treatment of bronchogenic carcinoma with mediastinal metastases. Ann Thorac Surg 12:11-17, 1971 Paulson DL, Reisch JS: Long-term survival after resection for bronchogenic carcinoma. Ann Surg 184:324-332, 1976 Shields TW, Yee J, Conn JH, Robinette CD: Relationship of cell type and lymph node metastasis to survival after resection of bronchial carcinoma. Ann Thorac Surg 20:501-510, 1975

Members of Veterans Administration Surgical Adjuvant Group Principal investigators: Dan E. Smith, Albuquerque, N. M.; Decio Rangel, Boston, Mass.; A. James McElhinney, Bronx, N. Y.; Harry H. LeVeen, Brooklyn, N. Y.; Thomas W. Shields, Lung Site Chairman, Chicago, 111.; Darryl J. Sutorius, Cincinnati, Ohio; Jerry S. Wolkoff, Cleveland, Ohio; R. W. Postlethwait, Esophagus Site Chairman, Durham, N. C ; Nae K. Cheung, East Orange, N. J.; Herbert Greenlee, Hines, 111.; Gene A. Guinn, Houston, Texas; Nelson Gurll, Iowa City, Iowa; J. Harold Conn, Jackson, Miss.; Robert A. Boudet, Kansas City, Mo.; Raymond C. Read, Little Rock, Ark.; George L. Juler, Long Beach, Calif.; Charles Frey, Pancreas Site Chairman, Martinez, Calif.; Joseph J. McCaughan, Jr., Memphis, Tenn.; Edward W. Humphrey, Colon-Rectum Site Chairman, Minneapolis, Minn.; Ernest F. Rosato, Philadelphia, Pa.; Felicien M. Steichen, Pittsburgh, Pa.; Jose H. Amadeo, San Juan, Puerto Rico; Robert C. Donaldson, Head and Neck Site Chairman, St. Louis, Mo.; Lloyd S. Rogers, Syracuse, N. Y.; George A. Higgins, Chairman, Washington, D. C ; Gale L. Mendeloff, Wood, Wis. Coordinator: Thomas F. Newcomb, Assistant Chief Medical Director for Research and Development, Department of Medicine and Surgery, Veterans Administration, Washington, D. C. Statistician: Robert J. Keehn, Medical Follow-up Agency, National Academy of Sciences-National Research Council, Washington, D. C. Discussion DR. ALTON O C H S N E R ,

JR.

Metairie, La.

I was interested to learn that cancer of the lung developed after 5 years in 25 of the patients in Dr. Shield's series. In our

44 3

large series, carcinoma of the lung developed after 5 years in only two patients^—those who had not stopped smoking. I think that figure demonstrates the role of smoking in the genesis of carcinoma of the lung. I would also like to report on a man who I believe is the oldest living survivor of pulmonary resection for malignant disease. The patient, a dirt farmer from Mississippi, was operated upon for fibrosarcoma on April 16, 1936, at the age of 19 years. At that time facilities were so antiquated that there was neither intensive care nor a recovery room. I wrote to the man 2 weeks ago and received this response from his wife: "Woodrow is doing good. He takes care of the cows every day." At the time there was some question as to what this lesion was. However, we have had it verified by a number of pathologists, and they all agreed that it was a fibrosarcoma. DR. R O B E R T J. J E N S I K Chicago, III.

Dr. Shields and his co-workers are to be commended for having accumulated a wealth of statistical data. As I review this material, certain aspects require emphasis and comment. Two hundred fifty-seven 10 year survivors out of a series of 2,238 patients represent about a 12 percent 10 year survival rate. Although a higher salvage is desirable, this certainly far surpasses results that can be achieved by chemotherapy or radiotherapy measures. Note that almost 20 percent of the operations were resections for undifferentiated tumors, and in over 27 percent, mention is made of hilar and/or mediastinal node involvement. The failure to increase survival by employing postoperative chemotherapy or preoperative radiation is disappointing, but perhaps newer drugs used in various combinations may increase survival percentiles. I have purposely selected a 6 year period from 1962 through 1967 in reporting our results from Rush-Presbyterian-St. Luke's Medical Center, because during that particular period preoperative radiation was in vogue and we certainly were enthusiastic participants in the cooperative study to assess the merits of that approach. Of 223 patients undergoing resection during that period, 39 lived 10 or more years, a 17 percent survival percentile. The breakdown of patients having no radiation versus those having preradiation is as follows: Twenty-eight of 131 without radiation therapy survived, for a 21 percent survival rate; by comparison, 11 of 92 subjected to preradiation survived for a 12 percent survival rate. Thus we would concur that survival in patients receiving preoperative radiation as a routine is not as good. In citing 120 survivors of pneumonectomy, 133 survivors of lobectomy, and four survivors of lesser resections, Dr. Shield's report does not give a breakdown as to the actual partition of the original group of patients. In other words, we do not know the survival figures of patients undergoing pneumonectomy, lobectomy, or less extensive resections. This breakdown in our 223 patients is as follows: There

44 4

The Journal of Thoracic and Cardiovascular Surgery

Shields et al.

were 60 pneumonectomies, 88 lobectomies, 30 sleeve lobectomies, and 45 segmentectomies, of which 30 were considered as curative resections. The corresponding numbers of surviving patients, nine, 13, eight, and nine, represent survival rates of 15, 15, 27, and 30 percent, respectively, indicating the merit of sleeve lobectomy and segmentectomy procedures. We question the lack of surgical versatility in the material reported, especially since emphasis is placed on the frequency of second primary tumors in the lung—10 percent in the 257 patients who survived 10 years. It is obvious that a patient who has a lobe spared as a result of a sleeve type resection or one who had more than one lobe remaining after segmentectomy can better withstand a second resective procedure. In our group of 39 survivors, there were eight patients, or 21 percent, with second primaries occurring from 2 to 9 years following the initial resection. Of the six who had undergone a second resection, four originally had segmentectomy. We still remain convinced that this type of selective limited resection is the procedure of choice. In the 21 year period from 1957 through 1977, actuarial survival in 155 patients undergoing curative segmental resection is as follows: 52 percent at 5 years, 32 percent at 10 years, and 18 percent at 15 years. Finally, I believe the surgical approach must be vigorously pursued and the results of Dr. Shields' report as well as other series brought to the attention of our medical confreres. Above all, surgical input must remain the sine qua non of final therapeutic assessment in any individual with bronchogenic carcinoma. DR. ANDRE P. NAEF Lausanne, Switzerland

Just a few words about our results compared to the extremely interesting paper of Dr. Shields, which may help us to understand many obscure points concerning survival after resection for cancer of the lung. My colleagues and I are about to study one recent series of 316 patients operated upon at least 5 years ago, and we have tried to define common denominators for 43 who survived 5 years. As you see here, 70 percent of the lesions were Stage I, 73 percent were squamous carcinoma, 61 percent were treated by lobectomy or 25 percent by left pneumonectomy, and 77 percent had a very short history. The good results after left pneumonectomy and the favorable influence of a short history have not been generally recognized and underline once more the great importance of early diagnosis. One more fact is worth mentioning, as Dr. Jensik said before. Eleven percent of our 5 year survivors had economic segmentectomies or sleeve resections. This type of operation should be more and more accepted in lung cancer surgery. The crux of the matter, consequently, is to get the patients early, so that radical, curative, and sometimes very economic operations can be performed. Until this happy day, the ideal candidate for lung cancer surgery remains the patient with

a short clinical history who has a Stage I epidermoid carcinoma that can be resected by lobectomy or by left pneumonectomy. DR. WILFORD B. NEPTUNE Boston, Mass.

I appreciate this paper by Dr. Shields because it points out once again that cancer of the lung is selectively curable. It seems that more and more people are spending more and more time doing tests to determine whether patients have incurable or inoperable disease. Frequently, the best approach might well be an exploration to establish a diagnosis; to allow adequate staging; and, with resection, to offer the best chance for cure. We have no argument concerning surgical therapy in the presence of visceral metastases or oat cell carcinoma, and patients with these lesions require careful work-up. However, about 12 percent of patients with T3 and N2 lesions will live 5 years or more following a resection. We have actually performed resections in about half (48 percent) of our group of 4,250 patients with lung cancer, and of these 25 percent were 5 year survivors. Thus our gross cure rate from the entire population was 12 percent. We recognize favorable aspects. There were 129 patients who had so-called survey carcinoma picked up by x-ray examination only, and 66 percent lived 5 years or more. However, among this large group of 416 who survived 5 years or more, 25 percent had nodal involvement, 40 percent had blood vessel invasion, and actually 20 percent of this entire group was treated by segmentectomy. I cannot say how many had a second tumor, but we have done a second resection for another tumor in about 6 percent of our long-term survivors. This point emphasizes once again Dr. Shields' recommendations that these patients be subjected to long-term careful examination. DR. J A M E S J.

YASHAR

Providence, R. I.

This excellent paper emphasizes again the importance of adequate long-term follow-up in patients with bronchogenic carcinoma. Four and one half years ago we reviewed 148 patients with bronchogenic carcinoma who underwent thoracotomy after an extensive preoperative evaluation. The resectability rate was 84 percent and the 5 year survival rate 34 percent. Involvement of the lymph node appeared to exert an unfavorable influence on the prognosis of the patient with bronchogenic carcinoma. The 5 year survival rate of patients with normal lymph nodes was 44 percent, in contrast to 25 percent and 0 percent survival rate when hilar nodes and mediastinal lymph nodes were involved. The 9Vi year follow-up reveals a survival rate of 24 percent with normal lymph nodes, 17 percent with interlobar nodes involved, and only 3 percent with hilar nodes involved. The 5 year and 9'/2 year survival rates were 34 and 15 percent, respectively. A second primary developed in 15 per-

Volume 76 Number 4 October, 1978

cent of patients, half of these lesions being bronchogenic carcinoma. I would like to ask two questions. First, is there any relationship between the size of the tumor and the long-term follow-up? Second, what was the effect of vascular invasion on the long-term follow-up of patients with bronchogenic carcinoma? DR. S H IE L D S (Cfoswg) I would like to thank the discussers. First, the Veterans Administration experience with preoperative irradiation was the same as Dr. Jensik's. We found it to be harmful rather than beneficial, so we do not recommend it. Regarding the results of lobectomy and pneumonectomy, the patients with lobectomies have done somewhat better than those with pneumonectomies. Those having segmentectomies and wedge resections have done reasonably well. However, we must remember that these patients were selected because they were poor risks owing to cardiopulmonary disease. Although they did not die of tumor, they died of their original underlying lung disease.

Lung carcinoma

44 5

We believe that the initial resection should be conservative of lung tissue as is commensurate with the disease process. This is the hallmark of modern day pulmonary surgery for bronchial carcinoma. We too believe that lymph node involvement does not preclude an adequate surgical resection. However, one must realize that the degree of lymph node involvement varies greatly. When mediastinal nodes are involved, the patients who survive are those who have intranodal disease rather than extranodal disease. The size of the lesion is likewise important. As in peripheral lesions, the prognosis for the smaller lesions is better than for the larger ones; that is, Tl's do better than T2's. Vascular invasion has not been a very adequate prognostic finding in our group of patients. It is much less significant than is lymphatic invasion or lymph node involvement. Finally, I would like to comment on Dr. Ochsner's remark concerning smoking. I can remember many years ago when I was smoking and heard him vilifying the cigarette smoker that I really didn't believe him. I do believe him now.