Resected Synchronous Primary Malignant Lung Tumors: A Population-Based Study

doi:10.1016/j.athoracsur.2007.07.091

The Annals of Thoracic Surgery

Volume 85, Issue 1, January 2008, Pages 204-209

https://doi.org/10.1016/j.athoracsur.2007.07.091 Get rights and content

Background

Synchronous lung tumors with a histology indicating primary lung carcinomas detected preoperatively or at surgery may represent intrapulmonary metastases from a primary tumor or two or more simultaneously occurring primary tumors. The situation is rare. This study was conducted to assess the characteristics and outcome for this patient group.

Methods

All clinical and pathology departments in Norway submit standardized reports on cancer patients to the Cancer Registry of Norway. The registry also has a law-regulated authority to collect supplemental information on diagnosis, treatment, and outcome for all cancer patients from hospitals. During the period 1993 to 2000, lung cancer was diagnosed in 15,308 patients, of whom 2528 underwent resection in 24 hospitals. This investigation included all patients with histology demonstrating primary lung carcinoma in more than one tumor in the resected specimen.

Results

Synchronous malignant tumors were found in 94 patients: 66 had two tumors and the remaining 28 had three or more. The tumors were of similar histology in 85 cases. The tumors were diagnosed preoperatively in 11 patients and peroperatively or in the resected specimen in the other 83. The 5-year relative survival rate was 31.4% for patients with squamous cell carcinomas, 23.2% for adenocarcinomas, and 42.7% for patients with tumors of other histology (two carcinoids).

Conclusions

Survival in patients with synchronous lung tumors is good compared with historical reports on patients with distant metastases or other variants of T4 tumors; thus, they should be considered for surgery.

Section snippets

Material and Methods

All patients resected for primary lung cancer in Norway since 1993 were identified in a comprehensive database at the Cancer Registry of Norway. Patients with more than one physically distinct tumor, separated from the index tumor by normal lung tissue, in the same or different lobe or lung, were classified as having synchronous primary tumors. The tumors had to be diagnosed during the course of initial surgical treatment, preoperatively, peroperatively, or postoperatively in the period 1993 to

Results

During the investigation period (1993 to 2000), 94 patients (40 women), with a mean age of 64 years (range, 41 to 83 years; Table 1), were found to have malignant synchronous tumors, representing 3.7% of all resections for lung cancer in Norway. Sixty-seven patients had two malignant tumors, and the remaining 27 had three or more. The tumors were confined to one lung in 90 cases, one lobe in 48, and multiple lobes in 46. In 73 patients, at least one tumor was located in an upper lobe.

Comment

The most important finding in this series is that surgical treatment in patients with synchronous primary lung tumors might be performed with an acceptable survival rate in an unselected, population-based cohort. Few patients were diagnosed with synchronous tumors preoperatively, but the situation may have changed with improved CT investigations preoperatively.

The strength of our study is the availability of a uniform database within a national cancer registry and the ability to track the

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An analysis of 26 studies including 1788 patients was performed. The pooled 5-year OS was 45% (95% confidence interval [CI], 37-53) of true SMPLC patients and 62% (95% CI, 57-67) of patients with pathologic stage I disease, which was different from the 5-year OS of 93% (95% CI, 85-100) of patients with multifocal GG/L lung cancers. Poor prognostic factors for SMPLC were lymph node metastasis (HR = 2.36; 95% CI, 1.75-3.20; P < .001) and pneumonectomy (HR = 2.96; 95% CI, 1.36-6.45; P = .006], whereas histology (HR = 1.11; 95% CI, 0.82-1.50; P = .508), laterality (HR = 1.16; 95% CI, 0.93-1.44, P = .190), sublobar resection (HR = 1.29; 95% CI, 0.90-1.84; P = .159), and adjuvant therapy (HR = 1.07; 95% CI, 0.64-1.80; P = .791) were not found to influence the outcome.
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Discordance in ALK rearrangements between primary tumors and metastases has also been reported.43 Most second primary lung cancers are consistently reported as being of the same major histotype (e.g., 2 adenocarcinomas, or 2 squamous cell carcinomas).9,44–66 Generally good outcomes are observed, suggesting that the assessment as two separate primary cancers was correct.
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A systematic review of the literature was conducted by a subcommittee of the International Association for the Study of Lung Cancer Staging and Prognostic Factors Committee to develop recommendations to identify second primary lung cancers. The process entailed review of knowledge relating to the mechanism of metastasis, determination of clonality, and outcomes of patients with resected tumors.
It is easier to determine that two tumors are different than that they are the same; finding similarities does not establish that they are the same. For example, most second primary lung cancers are of the same histotype. Few criteria are reliable by themselves; these include different histologic cancer types or matching DNA breakpoints by sequencing and a comprehensive histologic assessment of resected specimens. Characteristics that are suggestive but associated with potential misclassification include the presence or absence of biomarkers, imaging characteristics, and the presence or absence of nodal involvement.
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Original articleGeneral thoracicResected Synchronous Primary Malignant Lung Tumors: A Population-Based Study

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

J Thoracic Cardiovasc Surg

Chest

Chest

Ann Thorac Surg

Lung Cancer

Clin Lung Cancer

Lung Cancer

J Thorac Cardiovasc Surg

Chest

Original article
General thoracic
Resected Synchronous Primary Malignant Lung Tumors: A Population-Based Study