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7538 Background: The standard management for stage I non-small cell lung cancer is surgical resection and SBRT. Adjuvant therapy is typically not given in this group of lung cancer patients. Unfort...

Background . Sometimes microscopic residual tumor is found at the bronchial resection margin despite an apparently complete resection of lung cancer. This may adversely affect the patient's prognosis. Its impact on survival is unclear. Methods . The records of 834 patients with resected stage I non–small cell lung cancer were studied. Patients with complete resection were assigned to the complete resection group (n = 802); patients with microscopic residual tumor at the bronchial resection margin that was accepted were assigned to the residual tumor group (n = 23). Residual tumor was classified as carcinoma in situ, mucosal residual disease, or peribronchial residual disease. Results . The 5-year survival in the patients in the complete resection group was 54%; it was 58% in the residual tumor group with carcinoma in situ and 27.3% in the residual tumor group with invasive tumor (mucosal residual disease or peribronchial residual disease). The difference in survival between patients in the complete resection group and patients in the residual tumor group with invasive tumor was significant ( p = 0.03). Conclusions . The presence of mucosal or peribronchial residual disease, but not carcinoma in situ, at the bronchial resection margin in patients with stage I non–small cell lung cancer has an adverse effect on survival.

Background Stereotactic ablative radiotherapy (SABR) is a new treatment option for peripheral stage I lung cancer in patients unfit for surgical resection. SABR was introduced to Leeds Teaching Hospitals (LTHT) and Mid Yorkshire Hospitals (MYH) in May 2009. We sought to establish what effect the introduction of SABR had on surgical resection rates for stage I lung cancer, and compared clinical characteristics of patients receiving surgery, SABR, conventional radical radiotherapy (RRT) and best supportive care. Methods All patients diagnosed with stage I lung cancer from 2008 to 2011 were analysed for treatment modality, performance status (PS) and lung function. Results 565 stage I patients were studied and treatment rates over the 4 year period are shown below. The proportion of patients receiving SABR rates rose from 0% in 2008 to 26.1% in 2011. Surgical resection rates remained largely unchanged, but there was a reduction in the proportion of patients receiving best supportive care from 32.6% in 2008 to 13.7% in 2011. Overall radical treatment rates for the four years were 60%, 70.7%, 68% and 85% for 2008–2011 respectively. The proportion of patients with PS 0–1 were as follows: surgery 88%, SABR 39%, RRT 38% and BSC 13%. FEV 1 (l) (mean% predicted, 95% CI) was significantly higher in patients receiving surgery (80.1, 77.3–82.9) compared to those patients receiving SABR (62.1, 56.0–68.3, p For stage I lung cancer patients over the age of 75, the proportion of patients SABR rose from 0% in 2008 to 32.1% in 2011. Overall numbers of patients aged over 75 receiving BSC decreased over the four years; 49%, 45.5%, 38.6% and 24.4% for 2008–2011 respectively. Conclusion The introduction of SABR has led to a significant increase in overall radical treatment rates for patients with stage I lung cancer, without resulting in a sustained reduction in surgical resection rates. Patients undergoing SABR and RRT have worse lung function and performance status than those undergoing surgery.

7543 Background: Video-assisted thoracic surgery (VATS) is considered an alternative to open lobectomy for the treatment of non-small cell lung cancer (NSCLC). Limited data is available however, regarding the equivalence of open vs. VATS segmental resections, particularly among elderly patients. In this study, we used population-based data to compare postoperative and oncologic outcomes following open vs. VATS segmentectomy for early NSCLC. Methods: We identified all stage I NSCLC patients >65 year treated with VATS or open segmentectomy from the Surveillance, Epidemiology, and End Results registry linked to Medicare claims. We used propensity score methods to control for differences in the baseline characteristics of patients. Overall and lung cancer-specific survival of patients treated with VATS vs. open segmentectomy was compared after adjusting, stratifying, or matching patients based on their propensity score. We performed secondary analyses evaluating perioperative complications, need for intensive care unit (ICU) admission, extended length of stay, and perioperative mortality. These were repeated adjusting for physician characteristics (sociodemographics, specialty, and procedure volume). Results: Of the 577 study patients, 27% underwent VATS resection. VATS were mostly performed by high volume surgeons (p

9074 Background: There is paucity of published data addressing long term survivorship of patients treated with curative intent for stage I Lung cancer. Using a population based approach we planned ...

7570 Background: Patients with completely resected stage I lung cancer have the best survival. Stage I, as defined by Mountain in 1997, includes tumors of any size located within one lobe of the lung without involvement of the parietal pleura, a distance of 2 cm or more from the carina, and no evidence for metastatic disease in any pulmonary, hilar, or mediastinal lymph node or distant site. The 5-year survival for such patients is 57–67% (Mountain, 1997). We hypothesized that the introduction of FDG-positron emission tomography (PET) scanning would lead to upstaging of stage I patients with a consequential increase in survival. Methods: To test this hypothesis, we compiled a database of all patients with stage I lung cancer that underwent a complete surgical resection at the Moffitt Cancer Center from 1996 to 2006. Results: During this 11-year period, 1230 patients fulfilled these criteria. Surgery was performed by two thoracic surgeons (LR and ES). Description of pts: 638 women, 592 men; 11 African-American, 1215 Caucasian; 18 Hispanic, 1202 Non-Hispanic; age range 28.1–94.0 y, mean 68.9 y, median 69.9 y; 26 pneumonectomies, 243 segmentectomies or wedge resections; 699 adeno-, 15 adenosquamous, 325 squamous, 25 large cell, 57 neuroendocrine carcinomas; maximum tumor diameter range 0.1–25 cm, mean 2.9 cm, median 2.3 cm; 477 dead (survival 0.0–138.8 months), 753 alive (survival 0.1–144.4 months). The median OS by year of resection was: 88.0 m (1996, N=49), 61.2 m (1997, N=52), 72.1 m (1998, N=73), 58.0 m (1999, N=87), 83.6 m (2000, N=100), 75.0 m (2001, N=114), 70.7 m (2002, N=133), >55.7 m (2003, N=140), >41.5 m (2004, N=158), >33.1 m (2005, N=164), and >17.9 m (2006, N=160). These differences were not statistically significant (log-rank p=0.72). PET scanning was initiated at the beginning of the year 2000. The median OS for the 261 patients treated between 1996 and 1999 was 70.7 m (95% CI: 53.9–84.0), and the median OS for the 969 patients treated between 2000 and 2006 was 75.1 m (95% CI: 66.4–83.7). This difference was not statistically significant (log-rank p=0.34). Conclusions: We conclude that the introduction of PET scanning has not impacted on the survival of patients with stage I lung cancer at our institution. No significant financial relationships to disclose.

In 38 cases of Stage I lung cancer, for which surgery was not indicated because of poor cardiopulmonary function or other reason, radical irradiation yielded excellent results. The five year survival rate was 42.1%, the 10-year survival rate 28.4% and the 15-year survival rate 17.1%. Postradiation complications which can be life-threatening, were acceptably low in incidence, and there was no radiation-related death. The results support the concept of radical irradiation being acceptable as a treatment modality for Stage I lung cancer if the patients concerned cannot have surgery because of poor cardiopulmonary function or some other reason.

In 2 patients with stage I lung cancer, tumors recurred at their resection lines 10 years after the original surgical resections. These cases suggest that the prognosis of late cancer occurrences after resected primary lung malignancies might be related to the interval of time between primary and subsequent cancers rather than to their categorization as recurrent or metachronous cancers.

In Response: In response to Drs. Silvestri and Bach, it was clearly stated that all eight patients with clinical stage I lung cancer who had no treatment died of lung cancer in our response to the letters to the editor in the New England Journal of Medicine ([1][1]). The details of the procedures

2007;132;2062-2063 Chest Jerome Reich and James Asaph Natural History of Stage I Lung Cancer http://chestjournal.chestpubs.org/content/132/6/2062.full.html services can be found online on the World Wide Web at: The online version of this article, along with updated information and ISSN:0012-3692 ) http://chestjournal.chestpubs.org/site/misc/reprints.xhtml ( written permission of the copyright holder. this article or PDF may be reproduced or distributed without the prior Dundee Road, Northbrook, IL 60062. All rights reserved. No part of Copyright2007by the American College of Chest Physicians, 3300 Physicians. It has been published monthly since 1935. is the official journal of the American College of Chest Chest

Purpose: To investigate the use of IMRT for the treatment of stage I lungcancer associated with significant respiratory motion using 4DCT data. Method and Materials: A 4DCT scan ‐ covering a full respiratory cycle in 10 phases ‐ of a patient with a 1.8 cm diameter lungcancer was used to design several static step‐and‐shoot IMRT plans. Three plans were designed: two using snapshots of the tumor (mid‐inhale, full‐exhale), one using the superposition of all phases. Because of the significant tumor motion (maximum excursion of 2.5 cm) the effect of different margins around the CTV were studied. To reduce interplay between the MLC movement and respiratory motion in an ungated delivery, the number of intensity‐levels was minimized while maintaining coverage to the PTV and minimizing dose to OARs. Results: In this case‐study five‐field IMRT plans were generated using 18 MV photons delivering a total dose of 66 Gy in 33 fractions to the PTV. Plans based on snapshot scans of the lung only resulted in full coverage, if large margins (3 cm) were incorporated. All plans based on superimposed scans achieved full coverage, while allowing tight margins and minimizing the dosage to OARs. A small number of intensity‐levels (3–5 per beam) were sufficient for PTV coverage, thereby reducing the risk of unwanted interplay effects between MLC movement and respiratory motion. Conclusion: Using snapshot free‐breathing CT scans for treatment planning can lead to geometrical misses and underdosage of the target volume unless large PTV margins are applied at the expense of increased dose to OARs. Taking the superimposed CT scans of all respiratory phases for treatment planning ensures the full coverage of the tumor volume, without increasing dose to OARs. For this case‐study only a small number of segments were needed, allowing the application of IMRT despite significant tumor motion.

One hundred fifteen patients underwent resection for Stage I non-oat cell carcinoma of the lung. Each of these patients was evaluated carefully for extent of disease and classified as having a Stage I cancer only after the resected specimen was reviewed histologically and all regional nodes in the mediastinum were assessed. There were no deaths following operation. At 1 year of follow-up 75 of 81 patients (93 percent) were alive, and at 3 years, 77 percent were alive and free of disease. No patient had local recurrence and none was lost to follow-up. Patients with correctly staged early lung cancers have an excellent survival rate at 2 and 3 years with surgery alone. Merits of various adjuvant programs in this group of patients can be assessed correctly only if follow-up periods are prolonged and the numbers of patients evaluated are large.

Patients with stage I lung cancer can be offered surgical treatment with an excellent prognosis for recovery and long-term cure. The recent revision of the staging definition has rearranged the prognostic categories, further improving the prognosis in Stage I disease by eliminating patients with a higher risk of recurrence. The most vexing issues remaining are the infrequency of diagnosis of lung cancer at this stage and the increasing incidence of lung cancer of all stages, even among nonsmokers. Economical screening, abolition of cigarette smoking, control of airborne environmental carcinogens, and the continued search for effective systemic treatment remain challenges for the future.

A living vaccine, the bacille Calmette Guerin (BCG) strain of Mycobacterium tuberculosis bovis, has been administered in a single postoperative intrapleural dose as a controlled equivalent of postoperative empyema in 38 patients following pulmonary resection for lung cancer. This form of regional immunotherapy is reasonably well tolerated if the vaccine is given in a limited dose and if a follow-up course of isoniazid (INH) is administered. In this report, the technical details of this new therapeutic program are reviewed. The preliminary findings in a randomized prospective clinical trial of the technique indicate that patients with Stage I lung cancer are significantly benefited by the treatment. Patients with more advanced disease are unimproved by this form of therapy.

When the TNM staging system of the American Joint Committee (AJC) for Cancer Staging and End-Results Reporting was applied to 3,912 patients seen during a 6 year period at the Mayo Clinic, 624 (16%) fulfilled the criteria for postsurgical pathological Stage I non-small cell bronchogenic carcinoma. Of these 624 patients, 129 were excluded from further survival analysis for various reasons. The remaining 495 consisted of two groups: 350 patients who were enrolled within 30 days into a prospective postoperative 4 monthly follow-up program and 145 patients who were enrolled later or were followed less frequently. Because no significant difference was noted in survival rates between these groups, data were pooled. Of the combined group of 495 patients, 84% survived lung cancer for 2 years and 69% of 5 years (actuarial estimation). The survival of patients classified T1 N0 M0 (91% alive at 2 years and 80% at 5 years) is so good that it seems unlikely that adjuvant therapy in this group could demonstrate improved survival. In addition to TNM classification, age at operation, sex, and extent of operation were important determinants of survival.

We treated 112 patients with stage I lung cancer from 1973 through 1986. The overall 5-year survival rate was 59.5%. In T1N0M0 cases it was significantly better than in T2N0M0 cases (p< O. 05). There was no statistically significant difference in survival rate between patients who had complete dissection of mediastinal lymph node and those without it. The cause of death following resection of stage I lung cancer was mainly distant metastasis to the brain, lung or liver. Adjuvant therapy is recommended to improve the survival rate of patients with stage I lung cancer, especially those in the T2N0M0 classification.

Background: To assess for variables predicting pulmonary function test (PFT) changes after stereotactic body radiotherapy (SBRT) for medically inoperable stage I lung cancer. Methods: We reviewed 92 consecutive patients undergoing SBRT for stage I lung cancer between February 2004 and August 2007. A total of 102 lesions were treated using prescriptions of 20 Gy × 3 ( n = 40), 10 Gy × 5 ( n = 56), and 5 Gy × 10 ( n = 6). Institutional practice was 10 Gy × 5 before March 1, 2006 before changing to 20 Gy × 3 to conform to RTOG 0236 unless otherwise dictated clinically. Results: Median pretreatment forced expiratory volume at 1 second (FEV 1 ) was 1.21 liter (50% of predicted) and median diffusion capacity to carbon monoxide (DLCO) was 56.5. There was no significant overall change in PFT's after SBRT. Individual patients experienced both substantial improvements and declines (10% declined at least 14% predicted FEV 1 % and 19% predicted DLCO). The mean change in FEV 1 was −0.05 liter (range, −0.98 to +1.29 liter; p = 0.22) representing −1.88% predicted baseline FEV 1 (range, −33 to + 43%; p = 0.62). DLCO declined 2.59% of predicted (range, −37 to +33%; p = 0.27). Conformality index, V5 and V10 were associated with individual patient changes in FEV 1 % ( p = 0.033, p = 0.0036, p = 0.025, respectively), however, correlations were small and overall treatment dose did not predict for changes ( p = 0.95). There was no significant difference in FEV 1 ( p = 0.55) or FEV 1 % ( p = 0.37) changes for central versus peripheral locations. No factors predicted for individual changes in DLCO. Patients with FEV 1 % below the median of the study population had significantly longer overall survival ( p = 0.0065). Although patients dying of cardiac disease died earlier than those dying of other causes, FEV 1 % below median was not associated with a lower risk of dying of cardiac disease or with lower Charlson comorbidity index. Conclusions: (1) SBRT was well tolerated and PFT changes were minimal. (2) Central lesions were safely treated with 50 Gy.

Clinical outcomes following stereotactic body radiation therapy (SBRT) for stage I non-small cell lung cancer (NSCLC) are excellent, with local control rates ranging from 80% to 95% in medically inoperable patients. Toxicity following SBRT has been lower than expected, with exception for grade 3 to 5 events occurring in patients treated with high doses to mediastinal structures. In considering a randomized head-to-head comparison of SBRT versus surgery for stage I lung cancer, the interpretation of clinical response based on imaging is of great importance. This is because of the opportunity to salvage SBRT local failure with surgery in operable patients. The current literature is reviewed with respect to computed tomography (CT) and positron emission tomography (PET) with respect to response following SBRT. The reported toxicities following SBRT for both peripheral and central lung cancers are also reviewed.

Stage I lung cancer patients were benefited by intrapleural treatment with 107 colony-forming units of Tice-strain BCG. This improvement was dependent upon a negative tuberculin test prior to therapy.

Thirty-five patients with Stage I carcinoma of the lung were tested postoperatively to assess lymphoproliferative responses. Depressed lymphocyte proliferation (LP) responses to alloantaigen in the mixed leukocyte culture (MLC) as measured by thee relative proliferation index (RPI) were associated with a significantly shorter disease-free interval. In this group of patients, the immunologic responses predicted subsequent clinical course better than the TNM classification or the histological type of the tumor, and therefore this procedure appears promising for improved staging of patients with early stages of lung cancer (stage I lung cancer and T1N0M0). The depressed response to alloantaigen was a more sensitive discriminator of disease recurrence than PHA alone or even conbined with PHA.

A retrospective evaluation of 199 consecutive patients undergoing resection for lung cancer revealed a significantly shorter long-term survival for those in whom empyema developed postoperatively. The overall five-year survival for the empyema group was 24% compared with 35% in the control group (patients without empyema), and the median survival was 15 months for the empyema group versus 35 months for the control group. These differences in survival were not found among patients with Stage I lung cancer. Pneumonectomy proved to be the main risk factor for the occurrence of empyema after operation, but a minor risk factor was the anatomical extent of disease. This correlation may be explained by major surgical contamination or manipulation as well as by lower immunological host reaction, all related to the extent of the tumor. A lower immunological defense could also explain the worse outcome for patients with Stage II or III lung cancer in whom empyema developed postoperatively.

The accuracy of stage I lung cancer assessment achieved by traditional clinico-diagnostic staging was retrospectively evaluated in 164 consecutive patients who underwent thoracotomy. The diagnostic conversion rate was 6.7 % (1 carcinoid and 10 innocent pulmonary lesions) and occurred only in the subset of patients lacking preoperative pathologic confirmation (15 %). The conversion rate to unresectable tumor extent was 8 % (11/153), and local spread was the main cause of unresectability (5.5 %). The staging conversion rate was 29 % (43/153): the conversion rate for nodal evaluation was double that of primary tumor evaluation (24 % versus 12 %), but conversion to anatomically unresectable nodal diffusion occurred in only one patient (0.6 %). The ability of the surgeon to convert the wrong diagnosis was scanty without extemporary biopsy, and 7 patients with innocent lesions underwent standard resection for primary cancer. Surgical staging was as precise as pathological staging in primary tumor evaluation, but was faulty in nodal evaluation (15 % error in sN0 and sN1-2 assessment). It is concluded that following stage I lung cancer assessment by traditional means, supplementary examinations are requested for a better sensitivity of pathological confirmation and a better refinement of local spread. Better nodal evaluation has less value until a biologic limit to surgery for anatomically resectable nodal diffusion is universally accepted.

The National Institute of Radiological Sciences in Chiba, Japan (NIRS) has the highest number of patients with lung cancer treated with carbon ion beams in the world. This report describes the techniques and clinical trials that have been undertaken at NIRS and preliminary results of a current study on single-fraction irradiation. The data are compared to recent results for the treatment of peripheral stage I lung cancer from the literature.