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Surgery for young patients with lung cancer
Lung Cancer (2003) 42, 215 /220
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Surgery for young patients with lung cancer Da-Li Tian1, Hong-Xu Liu*,1, Lin Zhang, Hong-Nian Yin, Yong-Xiao Hu, Hui-Ru Zhao, Dong-Yi Chen, Li-Bo Han, Yu Li, Hou-Wen Li Department of Thoracic Surgery, First Hospital, China Medical University, Shenyang 110001, China Received 11 December 2002; received in revised form 2 May 2003; accepted 8 May 2003
KEYWORDS Young patients; Lung neoplasm; Surgery
Summary Objectives: To investigate the relationship between the clinical features and prognosis in young patients with lung cancer who underwent resection. Methods: Statistical analysis was employed on sex, age, symptoms, diagnosis, treatment and prognosis, in 92 young cases younger than 40 years old among 930 cases with primary lung cancer who underwent surgery from January 1978 to December 1996. Results: There were 92 young patients with lung cancer, accounting for 9.89% of the total cases. They were 71 male and 21 female patients, with the ratio of 3.38:1.The histological types were 34 squamous cell carcinomas (37%), 30 adenocarcinomas (33%), 26 small cell carcinomas (28%), and two large cell carcinomas (2%). On TNM staging, there were 30 cases in stage I (32.6%), 30 in stage II (32.6%) and 32 in stage III (34.8%). Lobectomy was conducted in 54 patients (59%), pneumonectomy in 36 (39%) and wedge-shaped resection in two cases (2%). The rate of pneumonectomy in young patients was significantly higher than that of 18% in older patients (/40) with lung cancer (P B/0.01). 57 patients (62%) received absolutely curative resection; 28 cases (30%), relatively curative resection; seven cases (8%), non-curative resection. The postoperative 5-year-survival was 46% (42/92), in comparison with 34% (288/838) in patients older than 40 receiving operation during the same period, with significant difference between the two groups (P B/0.05). The 5-year-survivals in patients with squamous cell carcinoma, adenocarcinoma, small cell carcinoma and large cell carcinoma were 68% (23/34), 30% (9/30), 38% (10/26) and 0 (0/2), respectively. The survival in squamous cell cancer was markedly higher than in adenocarcinoma (P B/ 0.01) and in small cell carcinoma (P B/0.05). There was no significant difference between adenocarcinoma and small cell cancer. The 5-year-survivals in stage I, II and III were 63% (19/30), 53% (16/30) and 22% (7/32), respectively. There was no significant difference between stage I and II, while remarkable difference was found between stage I and III (P B/0.01), and between stage II and III (P B/0.05). The 5-yearsurvival in patients undergoing absolutely curative resection was 67% (38/57), and 14% (4/28) in patients with relatively curative resection, with significant difference (P B/ 0.01). No patient survived longer than the 5th postoperative year in seven cases receiving non-curative resection. Conclusions: Young patients with lung cancer were more often seen in male than in female. Squamous cell carcinoma accounted for the most part, no statistical difference, however, compared with adenocarcinoma and small cell carcinoma. The pneumonectomy rate in young patients was remarkably higher than that in patients older than 40. The postoperative 5-year-survival in young
*Corresponding author. Tel.: /86-24-23256666-6256. E-mail address: [email protected] (H.-X. Liu). 1 These two authors contributed equally to this work. 0169-5002/03/$ - see front matter – 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0169-5002(03)00286-1
216
D.-L. Tian et al.
patients was considerably higher than in patients older than 40 who underwent surgery during the same period. Favorable prognosis was seen in patients with squamous cell carcinoma and undergoing absolutely curative resection, while worse outcome in stage III cancer. – 2003 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Lung cancer in young patients younger than 40 years of age is not commonly seen. It remains unclear on various factors affecting the surgical outcome. To investigate the clinical features of lung cancer in young patients, we retrospectively analyzed 92 patients.
with the index /600. Of these smoker patients, the histology component was 18 (56%) squamous cell carcinomas, six (19%) adenocarcinomas, and eight (25%) small cell lung cancers. Of the 16 cases with Brinkman Index /400, there were ten (63%) squamous cell carcinomas, two (13%) adenocarcinomas and four (25%) small cell lung cancers.
3.2. Symptoms and diagnosis
2. Patients and methods 2.1. Patients 930 cases of lung cancer underwent resection in the First Hospital of China Medical University from January 1978 to December 1996, including 92 young patients younger than 40 years old with cancer, accounted for 9.89%.
2.2. Methods Comprehensive factors including sex, age, smoking history, symptoms, diagnosis, surgery, histology, staging and prognosis were reviewed, in combination with the literature. 92 cases were diagnosed as lung cancer under microscope, and followed up for more than 5-years. The UICC Staging was used as criteria for staging. x2 was employed for the statistical analysis.
3. Results 3.1. General data The young patients with lung cancer were 71 male and 21 female, with the ratio of 3.38:1.The youngest was 13 (one female), seven cases aging from 21 to 29 (six male and one female), 84 patients aging from 31 to 39 (65 male and 19 female). 76 cases aged from 36 to 40, accounting for 82% (76/92) (Table 1). Of these patients, 32 cases including 30 male and two female patients, had smoking history, accounting for 35%. 16 cases (17%) were recorded with the Brinkman Index higher than 400, and only two cases
Of 81 patients (88%) with abnormal symptoms, cough was the initial symptom and most commonly seen in 67% (55/81) patients, followed by chest pain in 12% (10/81), hemoptysis in 9% (7/81), fever in 7% (6/81), and dyspnea in 4% (3/81). Both cough and hemoptysis as initial symtomps were recorded in 71% patients (39/55). The duration when confirmed diagnosis was obtained was, within 2 months after initial symptoms in 19 cases (21%), between 3 and 6 months in 41 cases (45%), from 6 to 12 months in nine patients (10%), longer than 1 year in 12 cases (12%). 11 cases (12%)were found with lung cancer without any specific symptoms. 45 cases (49%) were misdiagnosed as pneumonia, tuberculosis, bronchiectasis, rheumatoid, periarthritis of shoulder; cervical spondylosis. 32 cases received various kinds of therapy as anti-inflammation, anti-tuberculosis and anti-rheumatism for more than 2 months. Eight cases were monitored for over 6 months preoperatively. 50 tumors (54%) were in the right lung, and 42 (45%) in the left. 51 cases (55%) were considered as central type, which arose from the bronchi proximal to segmental brochus (including segmental bronchus), and 41 (45%) as peripheral type, which originated from the bronchi distal to segmental bronchus. Of the central-type tumors, there were 25 squamous cell carcinomas (49%), 18 small cell Table 1 Age distribution and sex Age
Male
Female
Total
10 /19 20 /29 30 /39 Total
6 65 71
1 1 19 21
1 7 84 92
Surgery for young patients with lung cancer
217
cancers (35%), and eight adenocarcinomas (16%), with significant difference between squamous cell carcinomas and other histological types. Of the peripheral tumors, there were 22 adenocarcinomas (54%), nine squamous cell carcinomas (22%), eight small cell carcinomas (20%), and two large cell carcinomas (5%), with significant difference between adenocarcinoma and other histological types.
cancer (38%) (P B/0.05), yet without remarkable difference between adenocarcinoma and small cell carcinoma (Table 2 and Fig. 2). There was no statistical difference between stages I and II, while very significant difference was seen between stage I and III (P B/0.01), significant difference existed between stage II and III (P B/0.05). The 5-yearsurvival was 24% in IIIA and 14% in IIIB, without significant difference in between (Table 2 and Fig. 3). The 5-year-survival of central type lung cancer was 55% (28/51), and 34% (14/41) for peripheral cancer, without significant difference between them. There was no significant difference concerning the 5-year-survival between patients receiving lobectomy and pneumonectomy. The difference was very significant between the absolutely and the relatively curative resection group (P B/0.01) (Table 3).
3.3. Histology, surgical approaches and prognosis 34 cases (37%) were squamous cell carcinomas, 30 (33%) adenocarcinomas, 26 (28%)small cell cancers, and two (2%) large cell cancers. Squamous cell carcinomas were more often seen than adenocarcinomas and small cell lung cancers, however, no statistic difference was observed among them. TNM staging: 30 (33%) cases were classified as stage I (4 IA, 26 IB), 30 (33%) as stage II (30 IIB), 32 (35%) as stage III (25 IIIA, 7 IIIB) (Table 2). In this study, 54 cases (59%) received lobectomy (including bilobectomy), 36 (39%) pneumonectomy, and two (2%) wedge-shaped resection. The pneumonectomy rate in patients /40 years of age during the same period was 18% (153/838), with significant difference compared with patients B/40 (P B/0.01). 57 cases (62%) underwent absolutely curative resection. 28 cases (30%) with N2 disease received relatively curative resection, which is defined as complete removal of primary tumors and extensive dissection of mediastinal nodes (R2) due to the mediastinal metastasis (N2) or tumor invasion of pleurae and adjacent lobes. Three cases (3%) of N3 or T4 disease got relatively non-curative resection, four cases (4%) underwent absolutely non-curative resection due to pleural dissemination or residual tumor after resection (Table 3). All cases were followed up for at least 5 years postoperatively, and the overall 5-year-survival was 46% (Fig. 1). The 5-year-survival in male patients was 44% (31/71), and 52% (11/21) in female. The 5-year-survival of squamous cell carcinoma (68%) was significantly higher than adenocarcinoma (30%) (P B/0.01) and small cell lung
4. Discussion Lung cancer in young patient is not commonly seen. It was reported that young patients with lung cancer in Europe and the States accounted for 1.2 / 3.1% of all the cases with lung cancer [1,2], and 3.5 /5.0% in Japan [3]. In our study, it is 9.89% (92/ 930), higher than that in Europe, the States and Japan. It was reported from most literatures that the ratio of male to female young patient with lung cancer ranged from 1.5:1 to 3.3:1 [1,4,12], also 0.36:1 from some report [3]. In our group, the ratio was 3.38:1, no statistical difference was seen compared with the group older than 40 years old during the same period (3.79:1). It is believed that smoking has very close relationship with lung cancer in young patients, and smokers accounted for over 90% [4 /6]. The smoker percentage in our study was similar with that from Japan [3]. No correlation was found between smoking and initiation of lung cancer in young adults as well as the prognosis. Only 33% (30 cases) in this study obtained correct diagnosis and underwent surgery early (within 2 months). Because lung cancer in young patient is
Table 2 Histology and the 5-year-survival of different TNM staging (%) TNM n
Squamous cell carcinoma
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma
Sum
I II III Sum
82 79 33 68
57 25 20 30
55 43 13 38
(0/1) 0 (0/1) 0 0 (0/2)
63 53 22 46
30 30 32 92
(9/11) (11/14) (3/9) (23/34)
(4/7) (2/8) (3/15) (9/30)
(6/11) (3/7) (1/8) (10/26)
(19/30) (16/30) (7/32) (42/92)
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Table 3 The 5-year-survival of different surgical approaches and curative resection Surgical approaches
N
Pneumonectomy
Lobectomy
Wedge-shaped resection
Sum
Absolutely curative resection Relatively curative resection Relatively non-curative resection Absolutely non-curative resection Sum
57 28 3 4 92
83 20 0 0 50
59 8 0 0 44
0 0 0 0 (0/2) 0 (0/2)
67 14 0 0 46
(15/18) (3/15) (0/2) (0/1) (18/36)
not common, the duration from early symptoms to confirmed diagnosis is relatively longer, which is the same case from the literature [3]. Other reports revealed that it was very possible, nearly 30%, to get misdiagnosis for lung cancer in young patient [3]. In our study, the misdiagnosis rate was 49%, and the diagnosis was usually confirmed after anti-inflammation, anti-tuberculosis and anti-rheumatism were employed. Therefore, for those with cough, bloody sputum and suspected mass shadow on chest X-ray film, further steps should be taken to attain the definite diagnosis, such as chest CT, PET, sputum cytology, bronchoscopy and percutaneous aspiration of lung tumor if necessary. For those whose definite diagnosis was not confirmed and were highly suspected of lung cancer, it was not beneficial to follow them up for longer period, an exploratory thoracotomy is advisable. The percentage of adenocarcinoma was higher from most literatures [1 /3,7,10 /13]. In this study,
Fig. 1
(23/39) (1/13) (0/1) (0/1) (24/54)
(38/57) (4/28) (0/3) (0/4) (42/92)
squamous cell carcinoma accounted for the most part, similar with adenocarcinoma, but no significant difference among different pathology. Most study so far suggested that the resection rate for lung cancer in young patients was lower and with poor prognosis, the postoperative 5-yearsurvival was below 35% [1,8,9,13]. In our group, the postoperative 5-year-survival in young adults B/40 years of age was 46%, significantly higher than that of patients older than 40 who underwent surgery during the same period (P B/0.05), demonstrating the better prognosis of lung cancer in young adults than in older patients /40. Another trial by Icard reported that the 5-year-survival was 70% in stage I, 54% in stage II, 28% in stage IIIA, and 0 in IIIB [2]. Our data suggested that there was no significant difference between stage I and II. The difference was remarkable between stage I and III, or stage II and III. Patients with stage III tumors had adverse prognosis, which was the same as that of Icard.
Survival curve of surgically resected lung cancer in young patients.
Surgery for young patients with lung cancer
219
Fig. 2 Survival curves of different histological types.
There were seven cases in IIIB stage, including one case with carinal invasion (T4N0), one with right supraclavicular nodal metastasis, one with contralateral mediastinal metastasis, two with contralateral hilar metastasis, one with involvement of right atrium (T4N2). Five cases underwent pneumonectomy, one lobectomy and one partial resection. For tumor invading carina, left pneumonectomy as well
as partial resection and reconstruction of carina was perform in one patient, resulting in absolutely curative resection, with the survival of over 5 years. The other six cases did not achieve absolutely curative resection, with the mean survival duration of 22 months. 57 (62%) patients received absolutely curative resection, and the 5-year-survival was 67%. 28
Fig. 3 Survival curves of different pathological TNM.
220
(30%) cases with mediastinal nodal metastasis (N2) or tumor invasion of pleura and adjacent lobes, underwent relatively curative resection (R2, complete removal of tumor along with mediastinal nodes), and the 5-year-survival was 14%. There was very significant difference between the absolutely curative resection and relatively curative resection group (P B/0.01). Non-curative resection was taken on seven cases, and postoperative radiation, chemotherapy and immunotherapy were employed, nonetheless, no patient could survive for 5 years. Our results reveal that early detection and early resection is of vital importance for the improvement of surgical efficacy in young patients with lung cancer. Patients with stage I and II cancers have favorable outcomes. Furthermore, absolutely curative resection is the key for the amelioration of prognosis. The pneumonectomy percentage in young patient was 39% (36/92), and considerably higher than that of 18% in patients older than 40 of age during the same period (P B/0.01). Among 18 patients underwent pneumonectomy and achieved absolutely curative resection, 15 cases survived for more than 5 years (83%). Among these 15 patients, six cases were N1 disease proved by pathology, some tumors could have been left over if lobectomy had been adopted. Pneumonectomy, thereafter, helped to achieve absolute curative resection, resulting in better prognosis. For this reason, pneumonectomy is highly recommended for curative resection and better prognosis in young patients with N1 lung cancer if possible.
D.-L. Tian et al.
References [1] Pemberton JH, Nagorney DM, Gilmore JC, Taylor WF, Bernatz PE. Bronchogenic carcinoma in patients younger than 40 years. Ann Thorac Surg 1983;36:509 /15. [2] Icard P, Regnard JF, de Napoli S, Rojas-Miranda A, Dartevelle P, Levasseur P. Primary lung cancer in young patients: a study of 82 surgically treated patients. Ann Thorac Surg 1992;54:99 /103. [3] Hirai T, Kawashima O, Kamiyoshihara M, Endoh K, Morishita Y, Maeshima A. A clinicopathologic study of lung cancer in patients under 40 years of age. Jpn J Lung Cancer 1997;37:357 /63. [4] Decaro L, Benfield JR. Lung cancer in young persons. J Thorac Cardiovasc Surg 1982;83:372 /6. [5] Putnam JS. Lung carcinoma in young adults. J Am Med Assoc 1977;238:35 /6. [6] Kyriakos M, Webber B. Cancer of the lung in young men. J Thorac Cardiovasc Surg 1974;67:634 /48. [7] Jubelirer SJ, Wilson RA. Lung cancer in patients younger than 40 years of age. Cancer 1991;67:1436 /8. [8] Antkowiak JG, Regal AM, Takita H. Bronchogenic carcinoma in patients under age 40. Ann Thorac Surg 1989;47:391 /3. [9] Green LS, Fortoul TI, Ponciano G, Robles C, Rivero O. Bronchogenic cancer in patients younger than 40 years old. The experience of a Latin American country. Chest 1993;104:1477 /81. [10] Kuo CW, Chen YM, Chao JY, Tsai CM, Perng RP. Non-small cell lung cancer in very young and very old patients. Chest 2000;117:354 /7. [11] Minami H, Yoshimura M, Matsuoka H, Toshihiko S, Tsubota N. Lung cancer treated surgically in patients B/50 years of age. Chest 2001;120:32 /6. [12] Maruyama R, Yoshino I, Yohena T, et al. Lung cancer in patients younger than 40 years of age. J Surg Oncol 2001;77:208 /12. [13] Skarin AT, Herbst RS, Leong TL, Bailey A, Sugarbaker D. Lung cancer in patients under age 40. Lung Cancer 2001;32:255 /64.
www.elsevier.com/locate/lungcan
Surgery for young patients with lung cancer Da-Li Tian1, Hong-Xu Liu*,1, Lin Zhang, Hong-Nian Yin, Yong-Xiao Hu, Hui-Ru Zhao, Dong-Yi Chen, Li-Bo Han, Yu Li, Hou-Wen Li Department of Thoracic Surgery, First Hospital, China Medical University, Shenyang 110001, China Received 11 December 2002; received in revised form 2 May 2003; accepted 8 May 2003
KEYWORDS Young patients; Lung neoplasm; Surgery
Summary Objectives: To investigate the relationship between the clinical features and prognosis in young patients with lung cancer who underwent resection. Methods: Statistical analysis was employed on sex, age, symptoms, diagnosis, treatment and prognosis, in 92 young cases younger than 40 years old among 930 cases with primary lung cancer who underwent surgery from January 1978 to December 1996. Results: There were 92 young patients with lung cancer, accounting for 9.89% of the total cases. They were 71 male and 21 female patients, with the ratio of 3.38:1.The histological types were 34 squamous cell carcinomas (37%), 30 adenocarcinomas (33%), 26 small cell carcinomas (28%), and two large cell carcinomas (2%). On TNM staging, there were 30 cases in stage I (32.6%), 30 in stage II (32.6%) and 32 in stage III (34.8%). Lobectomy was conducted in 54 patients (59%), pneumonectomy in 36 (39%) and wedge-shaped resection in two cases (2%). The rate of pneumonectomy in young patients was significantly higher than that of 18% in older patients (/40) with lung cancer (P B/0.01). 57 patients (62%) received absolutely curative resection; 28 cases (30%), relatively curative resection; seven cases (8%), non-curative resection. The postoperative 5-year-survival was 46% (42/92), in comparison with 34% (288/838) in patients older than 40 receiving operation during the same period, with significant difference between the two groups (P B/0.05). The 5-year-survivals in patients with squamous cell carcinoma, adenocarcinoma, small cell carcinoma and large cell carcinoma were 68% (23/34), 30% (9/30), 38% (10/26) and 0 (0/2), respectively. The survival in squamous cell cancer was markedly higher than in adenocarcinoma (P B/ 0.01) and in small cell carcinoma (P B/0.05). There was no significant difference between adenocarcinoma and small cell cancer. The 5-year-survivals in stage I, II and III were 63% (19/30), 53% (16/30) and 22% (7/32), respectively. There was no significant difference between stage I and II, while remarkable difference was found between stage I and III (P B/0.01), and between stage II and III (P B/0.05). The 5-yearsurvival in patients undergoing absolutely curative resection was 67% (38/57), and 14% (4/28) in patients with relatively curative resection, with significant difference (P B/ 0.01). No patient survived longer than the 5th postoperative year in seven cases receiving non-curative resection. Conclusions: Young patients with lung cancer were more often seen in male than in female. Squamous cell carcinoma accounted for the most part, no statistical difference, however, compared with adenocarcinoma and small cell carcinoma. The pneumonectomy rate in young patients was remarkably higher than that in patients older than 40. The postoperative 5-year-survival in young
*Corresponding author. Tel.: /86-24-23256666-6256. E-mail address: [email protected] (H.-X. Liu). 1 These two authors contributed equally to this work. 0169-5002/03/$ - see front matter – 2003 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/S0169-5002(03)00286-1
216
D.-L. Tian et al.
patients was considerably higher than in patients older than 40 who underwent surgery during the same period. Favorable prognosis was seen in patients with squamous cell carcinoma and undergoing absolutely curative resection, while worse outcome in stage III cancer. – 2003 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Lung cancer in young patients younger than 40 years of age is not commonly seen. It remains unclear on various factors affecting the surgical outcome. To investigate the clinical features of lung cancer in young patients, we retrospectively analyzed 92 patients.
with the index /600. Of these smoker patients, the histology component was 18 (56%) squamous cell carcinomas, six (19%) adenocarcinomas, and eight (25%) small cell lung cancers. Of the 16 cases with Brinkman Index /400, there were ten (63%) squamous cell carcinomas, two (13%) adenocarcinomas and four (25%) small cell lung cancers.
3.2. Symptoms and diagnosis
2. Patients and methods 2.1. Patients 930 cases of lung cancer underwent resection in the First Hospital of China Medical University from January 1978 to December 1996, including 92 young patients younger than 40 years old with cancer, accounted for 9.89%.
2.2. Methods Comprehensive factors including sex, age, smoking history, symptoms, diagnosis, surgery, histology, staging and prognosis were reviewed, in combination with the literature. 92 cases were diagnosed as lung cancer under microscope, and followed up for more than 5-years. The UICC Staging was used as criteria for staging. x2 was employed for the statistical analysis.
3. Results 3.1. General data The young patients with lung cancer were 71 male and 21 female, with the ratio of 3.38:1.The youngest was 13 (one female), seven cases aging from 21 to 29 (six male and one female), 84 patients aging from 31 to 39 (65 male and 19 female). 76 cases aged from 36 to 40, accounting for 82% (76/92) (Table 1). Of these patients, 32 cases including 30 male and two female patients, had smoking history, accounting for 35%. 16 cases (17%) were recorded with the Brinkman Index higher than 400, and only two cases
Of 81 patients (88%) with abnormal symptoms, cough was the initial symptom and most commonly seen in 67% (55/81) patients, followed by chest pain in 12% (10/81), hemoptysis in 9% (7/81), fever in 7% (6/81), and dyspnea in 4% (3/81). Both cough and hemoptysis as initial symtomps were recorded in 71% patients (39/55). The duration when confirmed diagnosis was obtained was, within 2 months after initial symptoms in 19 cases (21%), between 3 and 6 months in 41 cases (45%), from 6 to 12 months in nine patients (10%), longer than 1 year in 12 cases (12%). 11 cases (12%)were found with lung cancer without any specific symptoms. 45 cases (49%) were misdiagnosed as pneumonia, tuberculosis, bronchiectasis, rheumatoid, periarthritis of shoulder; cervical spondylosis. 32 cases received various kinds of therapy as anti-inflammation, anti-tuberculosis and anti-rheumatism for more than 2 months. Eight cases were monitored for over 6 months preoperatively. 50 tumors (54%) were in the right lung, and 42 (45%) in the left. 51 cases (55%) were considered as central type, which arose from the bronchi proximal to segmental brochus (including segmental bronchus), and 41 (45%) as peripheral type, which originated from the bronchi distal to segmental bronchus. Of the central-type tumors, there were 25 squamous cell carcinomas (49%), 18 small cell Table 1 Age distribution and sex Age
Male
Female
Total
10 /19 20 /29 30 /39 Total
6 65 71
1 1 19 21
1 7 84 92
Surgery for young patients with lung cancer
217
cancers (35%), and eight adenocarcinomas (16%), with significant difference between squamous cell carcinomas and other histological types. Of the peripheral tumors, there were 22 adenocarcinomas (54%), nine squamous cell carcinomas (22%), eight small cell carcinomas (20%), and two large cell carcinomas (5%), with significant difference between adenocarcinoma and other histological types.
cancer (38%) (P B/0.05), yet without remarkable difference between adenocarcinoma and small cell carcinoma (Table 2 and Fig. 2). There was no statistical difference between stages I and II, while very significant difference was seen between stage I and III (P B/0.01), significant difference existed between stage II and III (P B/0.05). The 5-yearsurvival was 24% in IIIA and 14% in IIIB, without significant difference in between (Table 2 and Fig. 3). The 5-year-survival of central type lung cancer was 55% (28/51), and 34% (14/41) for peripheral cancer, without significant difference between them. There was no significant difference concerning the 5-year-survival between patients receiving lobectomy and pneumonectomy. The difference was very significant between the absolutely and the relatively curative resection group (P B/0.01) (Table 3).
3.3. Histology, surgical approaches and prognosis 34 cases (37%) were squamous cell carcinomas, 30 (33%) adenocarcinomas, 26 (28%)small cell cancers, and two (2%) large cell cancers. Squamous cell carcinomas were more often seen than adenocarcinomas and small cell lung cancers, however, no statistic difference was observed among them. TNM staging: 30 (33%) cases were classified as stage I (4 IA, 26 IB), 30 (33%) as stage II (30 IIB), 32 (35%) as stage III (25 IIIA, 7 IIIB) (Table 2). In this study, 54 cases (59%) received lobectomy (including bilobectomy), 36 (39%) pneumonectomy, and two (2%) wedge-shaped resection. The pneumonectomy rate in patients /40 years of age during the same period was 18% (153/838), with significant difference compared with patients B/40 (P B/0.01). 57 cases (62%) underwent absolutely curative resection. 28 cases (30%) with N2 disease received relatively curative resection, which is defined as complete removal of primary tumors and extensive dissection of mediastinal nodes (R2) due to the mediastinal metastasis (N2) or tumor invasion of pleurae and adjacent lobes. Three cases (3%) of N3 or T4 disease got relatively non-curative resection, four cases (4%) underwent absolutely non-curative resection due to pleural dissemination or residual tumor after resection (Table 3). All cases were followed up for at least 5 years postoperatively, and the overall 5-year-survival was 46% (Fig. 1). The 5-year-survival in male patients was 44% (31/71), and 52% (11/21) in female. The 5-year-survival of squamous cell carcinoma (68%) was significantly higher than adenocarcinoma (30%) (P B/0.01) and small cell lung
4. Discussion Lung cancer in young patient is not commonly seen. It was reported that young patients with lung cancer in Europe and the States accounted for 1.2 / 3.1% of all the cases with lung cancer [1,2], and 3.5 /5.0% in Japan [3]. In our study, it is 9.89% (92/ 930), higher than that in Europe, the States and Japan. It was reported from most literatures that the ratio of male to female young patient with lung cancer ranged from 1.5:1 to 3.3:1 [1,4,12], also 0.36:1 from some report [3]. In our group, the ratio was 3.38:1, no statistical difference was seen compared with the group older than 40 years old during the same period (3.79:1). It is believed that smoking has very close relationship with lung cancer in young patients, and smokers accounted for over 90% [4 /6]. The smoker percentage in our study was similar with that from Japan [3]. No correlation was found between smoking and initiation of lung cancer in young adults as well as the prognosis. Only 33% (30 cases) in this study obtained correct diagnosis and underwent surgery early (within 2 months). Because lung cancer in young patient is
Table 2 Histology and the 5-year-survival of different TNM staging (%) TNM n
Squamous cell carcinoma
Adenocarcinoma
Small cell carcinoma
Large cell carcinoma
Sum
I II III Sum
82 79 33 68
57 25 20 30
55 43 13 38
(0/1) 0 (0/1) 0 0 (0/2)
63 53 22 46
30 30 32 92
(9/11) (11/14) (3/9) (23/34)
(4/7) (2/8) (3/15) (9/30)
(6/11) (3/7) (1/8) (10/26)
(19/30) (16/30) (7/32) (42/92)
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D.-L. Tian et al.
Table 3 The 5-year-survival of different surgical approaches and curative resection Surgical approaches
N
Pneumonectomy
Lobectomy
Wedge-shaped resection
Sum
Absolutely curative resection Relatively curative resection Relatively non-curative resection Absolutely non-curative resection Sum
57 28 3 4 92
83 20 0 0 50
59 8 0 0 44
0 0 0 0 (0/2) 0 (0/2)
67 14 0 0 46
(15/18) (3/15) (0/2) (0/1) (18/36)
not common, the duration from early symptoms to confirmed diagnosis is relatively longer, which is the same case from the literature [3]. Other reports revealed that it was very possible, nearly 30%, to get misdiagnosis for lung cancer in young patient [3]. In our study, the misdiagnosis rate was 49%, and the diagnosis was usually confirmed after anti-inflammation, anti-tuberculosis and anti-rheumatism were employed. Therefore, for those with cough, bloody sputum and suspected mass shadow on chest X-ray film, further steps should be taken to attain the definite diagnosis, such as chest CT, PET, sputum cytology, bronchoscopy and percutaneous aspiration of lung tumor if necessary. For those whose definite diagnosis was not confirmed and were highly suspected of lung cancer, it was not beneficial to follow them up for longer period, an exploratory thoracotomy is advisable. The percentage of adenocarcinoma was higher from most literatures [1 /3,7,10 /13]. In this study,
Fig. 1
(23/39) (1/13) (0/1) (0/1) (24/54)
(38/57) (4/28) (0/3) (0/4) (42/92)
squamous cell carcinoma accounted for the most part, similar with adenocarcinoma, but no significant difference among different pathology. Most study so far suggested that the resection rate for lung cancer in young patients was lower and with poor prognosis, the postoperative 5-yearsurvival was below 35% [1,8,9,13]. In our group, the postoperative 5-year-survival in young adults B/40 years of age was 46%, significantly higher than that of patients older than 40 who underwent surgery during the same period (P B/0.05), demonstrating the better prognosis of lung cancer in young adults than in older patients /40. Another trial by Icard reported that the 5-year-survival was 70% in stage I, 54% in stage II, 28% in stage IIIA, and 0 in IIIB [2]. Our data suggested that there was no significant difference between stage I and II. The difference was remarkable between stage I and III, or stage II and III. Patients with stage III tumors had adverse prognosis, which was the same as that of Icard.
Survival curve of surgically resected lung cancer in young patients.
Surgery for young patients with lung cancer
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Fig. 2 Survival curves of different histological types.
There were seven cases in IIIB stage, including one case with carinal invasion (T4N0), one with right supraclavicular nodal metastasis, one with contralateral mediastinal metastasis, two with contralateral hilar metastasis, one with involvement of right atrium (T4N2). Five cases underwent pneumonectomy, one lobectomy and one partial resection. For tumor invading carina, left pneumonectomy as well
as partial resection and reconstruction of carina was perform in one patient, resulting in absolutely curative resection, with the survival of over 5 years. The other six cases did not achieve absolutely curative resection, with the mean survival duration of 22 months. 57 (62%) patients received absolutely curative resection, and the 5-year-survival was 67%. 28
Fig. 3 Survival curves of different pathological TNM.
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(30%) cases with mediastinal nodal metastasis (N2) or tumor invasion of pleura and adjacent lobes, underwent relatively curative resection (R2, complete removal of tumor along with mediastinal nodes), and the 5-year-survival was 14%. There was very significant difference between the absolutely curative resection and relatively curative resection group (P B/0.01). Non-curative resection was taken on seven cases, and postoperative radiation, chemotherapy and immunotherapy were employed, nonetheless, no patient could survive for 5 years. Our results reveal that early detection and early resection is of vital importance for the improvement of surgical efficacy in young patients with lung cancer. Patients with stage I and II cancers have favorable outcomes. Furthermore, absolutely curative resection is the key for the amelioration of prognosis. The pneumonectomy percentage in young patient was 39% (36/92), and considerably higher than that of 18% in patients older than 40 of age during the same period (P B/0.01). Among 18 patients underwent pneumonectomy and achieved absolutely curative resection, 15 cases survived for more than 5 years (83%). Among these 15 patients, six cases were N1 disease proved by pathology, some tumors could have been left over if lobectomy had been adopted. Pneumonectomy, thereafter, helped to achieve absolute curative resection, resulting in better prognosis. For this reason, pneumonectomy is highly recommended for curative resection and better prognosis in young patients with N1 lung cancer if possible.
D.-L. Tian et al.
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