Prognosis of small cell lung cancer (SCLC) with brain metastases at diagnosis

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sonic esophagoscope equipped with 5-MHZ linear array transducer was applied to 25 cases of lung cancer for detecting tumor invasion and mediastinal lymph node metastasis. We comprehend the thoracic anatomy ultrasonically by discovering pulmonary artery and aortic arch, therefore it was easy to understand the positions of lesions and their mutual relation. The visualizations of tumors were possible in 14 cases (56%). Cancer invasions to the aorta were suspected in two cases and that we confirmed on these operation. In one case accompanied by atelectasis, tumor was not identified with ultrasound through chest wall, but was identified with this method. Three cases of dilated left brachiocephalic vein suggested us superior vena cava syndrome. Retrotracheal, subcarinal, subaortic and hilar lymph nodes were viewed with this method. About subaortic lymph nodes, this method was superior to CT scan in detecting and deciding the position of lymph nodes because these lymph nodes were existing between aorta and pulmonary artery. Multiple lymph nodes on this method were in almost all cases proved to be metastatic on operation or autopsy. However, it is difficult to identify whether lymph nodes were metastatic or not. Study on this point should be proceeded. Endoscopic ultrasonography has now become a helpful and indispensable method for diagnosing lung cancer. Real Time Sonography for Detecting Pleural Invasion in Lung Cancer. Tsuda, M., Kasashima, M., Murakami, M., Sugiyama, S., Kimoto, F., Koyama, S., Tatsumura, T., Yamamoto, K. Toyama Medical and Pharmaceutical University, ist Department of Surgery, Toyama, Japan. Ultrasound has been thought to be ineffective in pulmonary lesions, since aerated lung interposed between the lesion and the ultrasonic transducer will make visualization of the lesion impossible. We use ultrasonic evaluation in detecting pleural invasions in lung cancer, because, in such cases, tumors were adjacent to pleura, Real time sonography equipped with linear array transducer was performed in sixty patients in order to find out pleural invasions. Interruption of pleural echo and immovability with respiration are the signs of pelural invasions. Among the six cases with pleural involvement, US suggested transpleural invasion in four, four with gross and three with microscopic invasion. Conversely, of the five cases in which US was considered to show transpleural invasion, four h a d gross or microscopic involvement, or 4/5 false positive. Tumor extension into the chest wall was found at surgery in four patients. US de-

tected rib invasion in three patients. Under the presence of pleural effusion or atelectasis, it is easier to detect tumors which are not contiguous with pleura. Role of C.A.T. Scan in the Staging of Mediastinal Lymph nodes in the Patients Affected by Lung Cancer. Bazan, P., Filosto, G., Li Volsi, F., Damiani, E. Istituto di Clinica Chirurgica III, State University of Palermo, Sicily, Italy. In preoperative staging of lung cancer the eventual :nvolvement of mediastinal lymph nodes has had more and more importance, in order to achieve this purpose, presently we can use some diag,ostic tools like the traditional radiology, the C.A.T. scan and mediastinoscopy, but first a coarse selection of patients can be obtained with the traditional x-ray, which can show, by the study of the pleuro-mediastinal borders, the eventual lymph nodes involvement. This is particularly true, when we have the chance to detect very large adenophaties. The C.A.T. scan, instead, permits the identification of lymphnodal metastatic spreading whose dimensions are very small. The high clearance of this diagnostic way permits coming up some problems in the identification about the real nature, reactive or metastatic, of the mediastinal adenopathy. We have had the chance to correlate the real sensitivity of the C.A.T. scan, by direct proportional rate, to the number of involved nodes, so to achieve the 100% of sensitivity with three involved lymph nodes. The C.A.T. scan specificity, instead, is to correlate to nodes dimensions, because it increases when the involved nodes become more large with 100% of certainty for dimension superior to 2 cm. Finally we suggest the mediastinoscopic exam, when the C.A.T. shows the borderline cases: 1-2 cm of nodal dimensions; 2-3 modes involved. Prognosis of Small Cell Lung Cancer (SCLC) with Brain Metastases at Diagnosis. Zakem, M.H., Adelstein, D.J., Hines, J.D. Cleveland Metropolitan General Hospital, Case Western Reserve University, Cleveland, Ohio 44109. From 1978 to 1983 24/118 patients (20.3%) with SCLC at CMGH had brain metastases at diagnosis. Only 15/24 had neurologic signs or symptoms. These included weakness (2), ataxia (4), stroke syndromes (5), confusion/memory loss (2), stupor (1), and seizures (I). All patients had radiographic, and two had biopsy confirmation of metastases. Median survival for the 88/118 patients (74.6%) with extensive disease was 6.2 mo, Extensive disease patients without brain metastases had a median survival of 6 mo vs 7 mo for patients with brain metastases (p>0.5). Asymptomatic patients with brain metastases had a median survival of 7 mo vs 4 mo for symptomatic patients (p=0.47). Extended

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survival (ES) (> than 12 mo) was found in 6/24 (25,19,18,15+,14,13+ mo) while 7/24 had a short survival (SS) (< 1 mo). ES patients had an average ECOG performance status (PS) of 1.3 with none > 2 while SS patients had an average PS of 2.9. 2/6 ES patients had brain as the only site of metastases while 2/6 also had bone marrow metastases and 2/6 had bone metastases. SS patients had an average of 6.6 sites of metastases with liver involvement in 6/7. Treatment in ES patients consisted of 3500 to 3600 rads of whole brain radiotherapy (RT) as well as cyclophosphamide based on combination chemotherapy and RT to the primary lung lesion. Because of their rapid demise only 1 SS patient completed cranial RT. 3/7 received no cranial RT and 5/7 received no chemotherapy. In conclusion, the prognosis of SCLC with brain metastases at diagnosis is extreme~ ly variable. Prolonged survival is possible in those patients with good PS and minimal extracranial metastases. Those patients with multiple sites of extracranial metastases (especially hepatic) and poor PS have a dismal prognosis, often not surviving initial attempts at treatment. A M u l t i v a r i a b l e A n a l y s i s of Clinical Factors Predictive of Survival in 406 Stage Ill Non-Small Cell Lung Cancer CNSCLC) Patients Treated with High-Dose Cisplatin/ Vinca Alkaloid Regimens. O'Connell, J., Kris, M., Gralla, R., Fiore, J., Heelan, R., Kelsen, D., Groshen, S., Berenson, M., Golbey, R. Memorial SloanKettering Cancer Center, NY 10021, U.S.A. Performance status (PS), weight loss, presence of extrathoracic metastatic (met) disease, and involvement of specific met sites have been reported to be of prognostic importance in NSCLC. To analyze the significance of these and other factors, data was prospectively collected on 406 patients (pts) with unresectable NSCLC treated on 8 consecutive protocols from 197885, all pts having PS>50, creatinine clearance > 6~ cc/min, and receiving cisplatin (120 mg/m )/vinca alkaloid containing re~ gimens. Pretreatment variables studied were: PS, age, histologic type of NSCLC, stage III MO va MI, number of met sites, presence of bone, brain, or liver mets, prior RT or surgery, weight loss, LDH, and sex. In univariate analysis, significant factors were: PS, sex, presence of extrathoracic mets, more than one met site, bone mets, LDH and prior RT. Performing a multivariable analysis using the Cox proportional hazard model, survival was found to be adversely affected by: low PS(60-70) (median: 7.3 vs 12.4 mo, p < .001); male sex (8.8 vs 12.4 mo, p < .01); abnormal LDH (7.0 vs 14.0 mo, p < .001), and bone

mets (6.5 vs ii mo, p = .001). When major reSponse to chemotherapy was included in this multivariate analysis, it was independently predictive of prolongation of survival (17.8 va 6.4 mo, p < .01). We conclude: i) PS, sex, abnormal LDH, and bone mets are significant prognostic factors in NSCLC; 2) major response to chemotherapy is an independent variable associated with survival; and 3) design and reporting of future chemotherapy trials should incorporate data on these prognostic clinical variables. Supported by CA-05862 and the Tishberg Fund. Clinical Characteristics of Patients with Stage III Non-Small Cell Lung Cancer (NSCLC) receiving Combination Chemotherapy. O'Connell, J., Kris, M., Gralla, R., Fiore, J., Heelan, R., Kelsen, D., Groshen, S., Berenson, M. Memorial Sloan-Kettering Cancer Center, New York, NY 10021, U.S.A. Data from all patients (pts) entered at our institution from 1978-1984 on 8 consecutive chemotherapy protocols were reviewed to compare the clinical characteristics of our pts to prior large series (Green, Cancer 28: 1229, 1971; Lanzotti, Cancer 39: 303, 1977; Stanley, JNCI 65: 25, 1980). There were 406 patients with proven stage III NSCLC, performance status > 50%, creatinine clearance > 659cc/min, and treated with cisplatin (120 mg/m-)/vinca alkaloid containing regimens. Median age was 55, there were 69% males and 31% females. Histologic diagnoses included 67% adenocarcinoma, 25% epidermoid, and 8% large cell. Eighteen percent had localized, but unresectable, disease and 82% extrathoracic metastatic disease; this included 28% with bone metastasis (met), 10% with brain mets and 8% with liver mets. One-third of the group had more than one met site. Weight loss > 5% was present in 40% of pts. The median LDH was 233 (normal < 230). Conclusions regarding this group of pts with unresectable NSCLC are: i) there are more females and a younger age distribution than previously reported; 2) adenocarcinoma is now the most frequent histologic type in contrast to some earlier studies and surgical series; 3) approximately two-thirds of pts with unresectable disease do not have more than a single identified met site; 4) bone mets are more common than liver or brain met; and 5) earlier studies on the prognostic importance of clinical variables in unresectable NSCLC may not be applicable to the population undergoing combination chemotherapy in which the distribution of these variables may differ. Supported by CA05826 and the Tishberg Fund. Correlation of Cell Type and Sites of Metastases iniWomen With LunR Cancer. 2 Skoseyi, C., Hoffman 2 P'' Ferguson-, M.K., Golomb 2 H.M., Little , A.G., Bitran, J., Skinner , D.B. ~ e Univers~tM of Chlcag~,iDepartments of i. Medicine, 2. Surgery, D~4