Prevalence and pattern of nodal metastasis in pT4 gingivobuccal cancers and its implications for treatment.

Context: The pattern of nodal spread in oral cancers is largely predictable and treatment of neck can be tailored with this knowledge. Most studies available on the pattern are from the western world and for early cancers of the tongue and floor of the mouth. Aims: The present study was aimed to evaluate the prevalence and pattern of nodal metastasis in patients with pathologic T4 (pT4) buccal/alveolar cancers. Settings and Design: Medical records of the patients with pT4 primary buccal and alveolar squamous cell carcinomas treated by single-stage resection of primary tumor and neck dissection at Gujarat Cancer and Research Institute (GCRI), Ahmedabad, a regional cancer center in India, during September 2004 to August 2006, were analyzed for nodal involvement. Materials and Methods: The study included 127 patients with pT4 buccal/alveolar cancer. Data pertaining to clinical nodal status, histologic grade, pT and pN status (TNM classification of malignant tumors, UICC, 6th edition, 2002), total number of nodes removed, and those involved by tumor, and levels of nodal involvement were recorded. Statistical analysis was performed using the Chi-square test. Results: Fifty percent of the patients did not have nodal metastasis on final histopathology. Occult metastasis rate was 23%. All of these occurred in levels I to III. Among those with clinically palpable nodes, level V involvement was seen only in 4% of the patients with pT4 buccal cancer and 3% of the patients with alveolar cancer. Conclusions: Elective treatment of the neck in the form of selective neck dissection of levels I to III is needed for T4 cancers of gingivobuccal complex due to a high rate of occult metastasis. Selected patients with clinically involved nodes could be well served by a selective neck dissection incorporating levels I to III or IV.

Aspectos clínico-patológicos do carcinoma bronquioloalveolar e sobrevida em pacientes no estágio clínico I / Clinicopathological aspects of and survival in patients with clinical stage I bronchioloalveolar carcinoma

OBJETIVO: Analisar os aspectos clínico-patológicos do carcinoma bronquioloalveolar (CBA) e a sobrevida em uma amostra de pacientes com estadiamento clínico I. MÉTODOS: Foram estudados retrospectivamente 26 pacientes com diagnóstico de CBA e estágio clínico I, , segundo a classificação tumor-node-metastasis (TNM, tumor-linfonodo-metástase),(15)operados no Instituto de Doenças do Tórax da Universidade Federal do Rio de Janeiro, na cidade do Rio de Janeiro, RJ, entre 1987 e 2007, quanto a variáveis clínico-patológicas e radiológicas, mortalidade e sobrevida. Os dados foram colhidos dos prontuários médicos dos pacientes e analisados estatisticamente. RESULTADOS: Houve predomínio de mulheres (n = 16). A idade média ao diagnóstico foi de 68,5 anos. Houve predomínio de tabagistas (69,2 por cento). As formas de apresentação assintomática (84,6 por cento) e nodular (88,5 por cento) foram as mais comuns. Houve predileção pelos lobos superiores (57,7 por cento). O estágio patológico IB foi o mais comum, seguido pelos estágios IA e IIB (46,2 por cento, 38,4 por cento e 15,4 por cento, respectivamente). Não houve óbitos hospitalares. Quatro pacientes faleceram durante o seguimento pós-operatório, com tempo livre de doença médio de 21,3 meses. A taxa de sobrevida global em cinco anos foi 83 por cento. A probabilidade de sobrevida para os pacientes diagnosticados depois de 1999 tendeu a ser maior do que para aqueles diagnosticados até 1999 (taxa de sobrevida em três anos: 92 por cento vs. 68 por cento; p = 0,07). CONCLUSÕES: Os aspectos clínico-patológicos da amostra estudada foram semelhantes àqueles de estudos anteriores em pacientes com CBA.

OBJECTIVE: To analyze the clinicopathological aspects of bronchioloalveolar carcinoma (BAC) and the survival in a sample of patients at clinical stage I. METHODS: A retrospective study involving 26 patients diagnosed with clinical stage I BAC and undergoing surgery at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro, in the city of Rio de Janeiro, Brazil, between 1987 and 2007. We analyzed clinicopathological and radiological aspects, as well as mortality and survival. The data, which were collected from the medical charts of the patients, were statistically analyzed. RESULTS: Females predominated (n = 16). The mean age at diagnosis was 68.5 years. Most patients were active smokers (69.2 percent). The most common forms of presentation of BAC were the asymptomatic form (84.6 percent) and the nodular form (88.5 percent). Involvement of the upper lobes predominated (57.7 percent). Stage IB was the most common pathological stage, followed by stages IA and IIB (46.2 percent, 38.4 percent and 15.4 percent, respectively). There was no in-hospital mortality. Four patients died during the postoperative follow-up, with a mean disease-free survival time of 21.3 months. The overall five-year survival rate was 83 percent. The probability of survival for the patients diagnosed after 1999 showed a trend toward an increase when compared with that for those diagnosed up through 1999 (three-year survival rate: 92 percent vs. 68 percent; p = 0.07). CONCLUSIONS: The clinicopathological aspects of this study sample were similar to those of patients with BAC evaluated in previous studies.

Um caso raro de tumores torácicos malignos sincrônicos / A rare case of synchronous malignant thoracic tumors

Tumores neurogênicos malignos do mediastino em adultos são raros e extremamente agressivos. Este artigo relata o caso de um paciente de 61 anos com a ocorrência simultânea de schwannoma maligno de mediastino e carcinoma bronquíolo-alveolar. Apesar do carcinoma bronquíolo-alveolar estar presente em 4-7 por cento dos tumores torácicos sincrônicos ressecados, essa associação nunca foi apresentada na literatura. É, no entanto, um achado frequente em pacientes com infiltrados aparentemente inflamatórios e com opacidades em vidro fosco, como apresentado neste caso.

Malignant neurogenic mediastinal tumors in adults are uncommon and extremely aggressive. We report the case of a 61-year-old male patient with the simultaneous occurrence of malignant mediastinal schwannoma and bronchioloalveolar carcinoma. Although bronchioloalveolar carcinoma is present in 4-7 percent of the resected synchronous thoracic tumors, this association has never been reported in the literature. However, it is a common finding in patients presenting apparently inflammatory infiltrates and ground-glass opacities, as in the case presented here.

Malignant Pure Pulmonary Ground-Glass Opacity Nodules: Prognostic Implications

OBJECTIVE: This study was designed to evaluate follow-up results in terms of patient prognosis for malignant pulmonary nodules depicted as pure ground-glass opacity (GGO) lesion observed at high-resolution CT (HRCT). MATERIALS AND METHODS: Surgical removal for malignant GGO nodules was accomplished in 58 patients (26 men, 32 women; mean age, 57 years; age range, 29-78 years). Patient prognoses were assessed by patient clinical status and the presence of changes in nodule size determined after a follow-up HRCT examination. Differences in patient prognoses were compared for nodule number, size, surgical method, change in size before surgical removal, and histopathological diagnosis by use of Fisher's exact test and Pearson's chi-squared test. RESULTS: Of the 58 patients, 40 patients (69%) were confirmed to have a bronchioloalveolar carcinoma (BAC) and 18 patients (31%) were confirmed to have an adenocarcinoma with a predominant BAC component. Irrespective of nodule size, number, treatment method, change in size before surgical removal and histopathological diagnosis, neither local recurrence nor a metastasis occurred in any of these patients as determined at a follow-up period of 24 months (range; 12-65 months). Of 14 patients with multiple GGO nodules, all of the nodules were resected without recurrence in six patients. In the remaining eight patients, the remaining nodules showed no change in size in seven cases and a decrease in size in one case as determined after a follow-up CT examination. CONCLUSION: Prognoses in patients with pure GGO malignant pulmonary nodules are excellent, and not significantly different in terms of nodule number, size, surgical method, presence of size change before surgical removal and histopathological diagnosis.

Caracteríticas clínicas, diagnósticas e laboratoriais de portadores de carcinoma bronquioloalveolar / Clinical, diagnostic, and laboratory characteristics of patients with bronchoalveolar carcinoma

O carcinoma bronquioloalveolar (CBA) é um subtipo de adenocarcinoma, representa menos de 5 por cento dos tumores primários do pulmão, e possui características patológicas próprias. Poucos trabalhos foram publicados no Brasil.Objetivo: Estudar as características do carcinoma bronquioloalveolar em pacientes com diagnóstico de carcinoma broncogênico. Métodos: Estudo retrospectivo com levantamento de dados dos prontuários de pacientes do ambulatório de Oncopneumologia da UNIFESP (São Paulo). Resultados: Dos 1.617 pacientes com diagnóstico de carcinoma broncogênico, 45 (2,8 por cento) eram CBA. Predominou o sexo feminino (53,3 por cento), a cor branca (maior que 70 por cento) e 64,4 por cento dos pacientes apresentaram história de tabagismo. Os principais sintomas foram: tosse (80 por cento), expectoração (68,9 por cento) e dispnéia (60 por cento). Os pacientes levaram em média 10,27 meses para procurar o ambulatório. As imagens radiológicas predominantes foram de padrão difuso. O método diagnóstico mais utilizado foi a broncoscopia (71,2 por cento). Conclusão: Os resultados encontrados são semelhantes aos da literatura mundial. No Serviço de Oncopneumologia da UNIFESP,se faz mais diagnósticos pela biópsia por broncoscopia.

Tamaño del tumor y supervivencia en carcinoma de pulmón, estadio IA / Tumor size and survival in lung cancer, stage IA

El estadio determinado por el sistema TNM (tumor, ganglios, metástasis) sigue siendo el factor predictor de supervivencia más importante en el carcinoma de pulmón. Sin embargo, varios estudios demostraron que el tamaño del tumor tenía valor pronóstico en sí mismo, aunque la relación entre tamaño tumoral y supervivencia dentro del grupo de tumores T1 todavía no es clara. El objetivo del presente estudio fue evaluar el valor del tamaño del tumor como factor pronóstico para la supervivencia en pacientes con carcinoma de pulmón de estadio IA, resecado quirúrgicamente. Se revisaron 79 pacientes con carcinoma de pulmón de células no pequeñas. En 34.4% de los pacientes (n = 28) el tamaño fue igual o menor a 1.5 cm. La mortalidad operatoria fue de 1.3%. Hubo recurrencia de la enfermedad en el 19%. Los pacientes con tumores de hasta 15 mm tuvieron una supervivencia a los 5 años de 95% (IC: 0.05) y con más de 15 mm, de 77%. (IC: 0.07), siendo la diferencia estadísticamente significativa (log-rank test: 0.035). La supervivencia libre de enfermedad fue de 95% en los tumores de hasta 15 mm y de 72% (IC: 0.09) en los de más de 15 mm. El análisis multivariado (Cox) mostró que el mayor determinante del riesgo de mortalidad fue el tamaño mayor de 15 mm (riesgo relativo 25.9, IC: 2.3-292, p = 0.004). Este estudio demuestra la influencia del tamaño del tumor en estadio IA, lo cual puede tener importancia práctica en función de las recientes propuestas de investigación sistemática de pacientes con alto riesgo de cáncer pulmonar.

TNM staging is an important long-term predictor for survival of lung cancer patients. Some studies have shown, however, that tumor size may have intrinsic prognostic value independent of TNM stage. The relationship between tumor size and survival is particularly unclear in T1 tumors. The objective of this study was to assess the prognostic value of tumor size in surgically resected stage I of non-small cell lung cancer (NSCLC). Clinical records of 79 patients with stage IA NSCLC were reviewed. In 34.4% of patients (n = 28) size was ≤ 1.5 cm. Surgical mortality was 1.3%. Disease recurrence was noted in 19%. Patients with tumors ≤ 15 mm had a significantly higher 5-year survival (95% CI:0.05 vs. 77% CI: 0.07 in > 15mm group). Disease-free survival was 95% for tumors less than 15 mm vs. 72% in larger tumors. Using Cox Multivariate analysis, the most determinant factor for higher risk of mortality was size >15 mm (relative risk 25.9, IC: 2.3-292, p = 0.004). The independent influence of tumor size in stage IA NSCLC may have practical implications with regards to proposals for screening asymptomatic individuals at high risk for lung cancer.

Distribution of basal / myoepithelial cells in well-differentiated adenocarcinoma and bronchioloalveolar proliferations of the lung

We investigated the staining pattern of commonly used basal cell/ myoepithelial markers such as p63 [a p53-homologous nuclear protein], basal cell-specific cytokeratin antibody [34 [3E12, K903] and smooth muscle myosin heavy chain [SMMHC] in benign and malignant bronchioloalveolar proliferations of the lung. Eighty-five lung lesions were included in the study, consisting of 35 bronchioloalveolar carcinoma, 30 well differentiated adenocarcinoma and 20 cases of benign lung lesions. In normal lung, p63, K903 and SMMHC decorated the basal cells of large and small airways and occasional cells of terminal bronchioles. In reactive processes, a distinctive staining pattern was present in 19/20 [95%] of the cases, characterized by staining of basal cells of the airways as well as bronchiolar-and squamous metaplastic epithelium for p63 and K903, while 12/20 [60%] stained with SMMHC. Respiratory ciliated cells, alveolar epithelial cells and nonepithelial cells were negative. In bronchioloalveolar carcinoma, a discontinuous peripheral rim of p63-immunoreactive cells was retained surrounding and intermingled with the malignant bronchioloalveolar proliferation in 31/35 [88.5%] cases, SMMHC in 28/35 [80%] and K903 in 20/35 [57%] cases. For adenocarcinoma, the majority of cases [28/30, 93%] were negative for p63 and K903; however, SMMHC showed artifactual staining in the desmoplastic stroma in 6/30 [20%] cases. Our results highlighted the differential expression of basal cell markers across various bronchioloalveolar lesions. The staining pattern of basal cells in bronchioloalveolar carcinoma support that these neoplasms may actually be carcinoma in-situ, which would explain their good prognosis and their tendency not to metastasize

Carcinoma broncoalveolar: sobrevida a cinco años / Bronchioalveolar carcinoma: five year survival

The epidemiology and prognosis of bronchioalveolar carcinoma (BAC) is different from adenocarcinoma. We studied 28 patients who underwent surgical resection and in whom a final histologic diagnosis of bronchioalveolar carcinoma was made. Sixty one percent of patients were asymptomatic at the time of diagnosis. The most usual radiological presentations were pulmonary nodule (11), pulmonary mass (6) and diffuse infiltrate (6). Nine patients (9/25) were never smokers. Bronchoscopy provided the diagnosis only in 4/26 patients. Patients were classified as stage IA 11/24, IB 5/24 IIIB in 2/24 and IV in 6/24. Five-year survival for the entire group was 65%. Patients with focal lesions had a longer survival. The survival in patients who underwent potentially curative resections was 62.8 +/- 44.0 months. When surgery was considered non-curative, survival was 21.2 +/- 19.5 months (p = 0.0064). Five-year survival in stage IA patients was 80%. Survival of patients with non-mucinous histology was longer than those with mucinous type carcinomas (54.9 +/- 25.0 months vs. 5.33 +/- 4.04, p < 0.0001) but the 5-year-survival was not statistically different. In conclusion, BAC has a favourable prognosis. The best survival rate was found in focal forms, represented by early tumor, nodes, metastasis (TNM) stages and non-mucinous BAC among the histological groups.

Carcinoma bronquílo-alveolar associado à malformaçäo adenomatóide cística de tipo I: relato de caso e revisäo de literatura / Bronchioalveolar carcinoma complicating type I congenital cystic adenomatoid malformation: case report and review of literature

Paciente masculino de 36 anos, com cisto uniloculado no pulmäo direito, revestido por epitélio cilíndrico ciliado com atipias reativas e focos de metaplasia mucinosa. No tecido pulmonar adjacente, observou-se proliferaçäo epitelial mucossecretora focal nos septos alveolares, com discreta atipia nuclear. Estabeleceu-se o diagnóstico de carcinoma bronquíolo-alveolar mucinoso associado à malformaçäo adenomatóide cística congênita de tipo I. A provável disseminaçäo aerógena e o caráter multicêntrico desta neoplasia reforçam a importância da ressecçäo precoce das lesöes. Lobectomia complementar detectou a presença de dois outros focos de carcinoma no tecido pulmonar contíguo

Osteoartropatía hipertrófica asociada a carcinoma bronquioalveolar / Hypertrophic osteoarthropathy associated with bronchioloalveolar carcinoma

La osteoartropatía hipertrófica (OAH) es una entidad clínica poco frecuente, que en general se asocia a neoplasias pulmonares. Se presenta el caso de un paciente de 55 años, fumador, que consultó en múltiples oportunidades en los últimos 2 años por cuadro de poliartralgias simétricas. Evaluados en Reumatología se sospechó una OAH secundaria. Se solicitó una radiografía de tórax en la que se detectó un nódulo pulmonar solitario en la periferia del lóbulo inferior izquierdo. A través de una toracotomía se realizó lobectomía y linfadenectomía mediastinal. La biopsia demostró un carcinoma bronquiloalveolar. Luego de la resección del tumor, la sintomatología articular desapareció

Biopsia por aspiración con aguja delgada en lesiones torácicas. Análisis de 60 casos en un Hospital General de Zona / Thinn needle aspiration biopsy in thoracic lesions. Analysis of 60 casos in a General Zone Hospital

El objetivo del trabajo fue demostrar la utilidad de la biopsia por aspiración con aguja delgada (BAAD) de lesiones torácicas en un hospital de segundo nivel, que no contaba con la tecnología idónea para localizar las lesiones, verbigracia: tomografía computarizada, fluoroscopía, intensificador de imágenes y ultrasonografía. Con el empleo de estudios radiológicos simples posteroanteriores y laterales y el trazo de coordenadas verticales y horizontales, se puncionaron 77 pacientes. En 60 (77.9 por ciento) se obtuvo material apropiado, en 7 (11.6 por ciento) casos fue necesario puncionar en dos ocasiones. La BAAD demostró neoplasia maligna en 46 (76.7 por ciento) pacientes y enfermedad benigna en 14 (23.3 por ciento). Los diagnosticos más frecuentes fueron carcinoma epidermoide en 20 (33.3 por ciento) casos, carcinoma indiferenciado en 7(11.6 por ciento) y carcinoma bronquioloalveolar en 7 (11.6 por ciento). En 12 pacientes se practicó biopsia a cielo abierto y en 2 necropsia, en todos ellos hubo correlación con el diagnóstico de la BAAD. Cuatro (6.6 por ciento) pacientes se complicaron con neumotórax, en 3 se resolvió espontáneamente y uno amerito aplicación de sello de agua. Se demostró la utilidad de la BAAD en tórax en un hospital con recursos tecnológicos limitados, se diagnosticó 77.9 por ciento de los enfermos con un costo ínfimo, sin mortalidad y con mínima morbilidad

Carcinoma bronquioloalveolar: relato e estudo de 2 casos / Bronchioloalveolar carcinoma: report and study of 2 cases

Os autores relatam dois casos de carcinoma bronquioloalveolar - uma forma particular de adenocarcinoma de pulmao - em pacientes nao-fumantes do sexo feminino. Evidenciam achados clínico-radiológicos característicos da neoplasia, discutindo sua peculiar história natural, chamando atençao para a associaçao com esclerodermia - doença do tecido conjuntivo, apresentada por uma de nossas pacientes.

Neoplasia primaria de pulmao em paciente com cancer de mama: relato de um caso / Primary lung neoplasm in patient with breast neoplasm: report of a case

Nodulo pulmonar em paciente com diagnostico previo ou concomitante de neoplasia maligna de outra origem, nem sempre e sinonimo de lesao metastatica. Em se tratando de cancer de mama e nodulo pulmonar solitario isso se torna importante pois na maioria das vezes a lesao pulmonar nao se relaciona ao tumor primario previo, podendo tratar-se de neoplasia de pulmao. Apresentamos o caso de um paciente de 69 anos, branca, mastectomizada ha quatro anos, na qual se encontrou um nodulo pulmonar solitario que, ressecado, teve como diagnostico anatomo-patologico, tumor bronqioloalveolar intravascular, uma lesao pouco frequente, e que nessa paciente se apresentou de forma incomum.