Pleomorphic carcinoma of the lung: which CT findings predict poor prognosis?

Transcription

1 Pleomorphic carcinoma of the lung: which CT findings predict poor prognosis? Poster No.: C-1887 Congress: ECR 2015 Type: Scientific Exhibit Authors: A. Fujisaki, T. Aoki, S. Kinoshita, Y. Hayashida, Y. Korogi, F. Tanaka, H. Mukae; Kitakyushu/JP Keywords: DOI: CT, Lung, Surgery, Cancer /ecr2015/C-1887 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 17

2 Aims and objectives Background Pleomorphic carcinoma (PC) is a subtype of sarcomatoid carcinoma that contains a component of sarcoma or sarcoma-like (spindle and/or giant cell) differentiation. According to the criteria of the World Health Organization (WHO) classification, PC of the lung is defined as a poorly differentiated non-small cell lung carcinoma containing spindle cells and/or giant cells or, a carcinoma consisting only of spindle and giant cells [1]. At least 10% of the carcinoma should comprise spindle and/or giant cells for it to be classified as a PC. This tumor is rare, and its incidence has reported 0.1% to 0.4% of all lung malignancies [2, 3]. The patients with PC tend to present at a more advanced stage and to have a poorer prognosis than common non-small cell lung carcinomas [3-5]. Although several clinicopathologic studies of lung PC have been reported in the literature, there were a few previous reports about its radiologic features [6, 7]. Moreover, to our knowledge, the correlation of these CT findings with prognosis has not been described. PuPurpose To assess the radiological and clinical findings of the lung PC and to evaluate if there are any characteristic features that predict the prognosis Methods and materials Patients Forty-four consecutive patients whose diagnosis of PC was histologically confirmed through the resection of lung tumor. The clinical findings (age, gender, smoking habits, stage, and outcome) on medical records were retrospectively reviewed. CT scanning and image review Postcontrast CT images of 1-2 mm thickness were obtained with 4-, 16-, 32- or 64-detector row CTs. Two chest radiologists analyzed the CT findings for: size and location of tumors, internal characteristics (central low attenuation, cavity, and Page 2 of 17

3 calcification), margin characteristics, chest wall and/or mediastinal invasion, and surrounding lung abnormality (emphysema or interstitial pneumonia), and final decision was reached by consensus. In the 8 patients who had undergone a previous CT before surgery, the tumor doubling times (TdTs) were calculated using the method by Schwartz. Statistical analysis Overall/disease-free survivals were calculated according to the Kaplan- Meier method. A multivariate analysis by the Cox proportional hazard model was used to identify variables that predict prognosis. Results Clinical features Of the 44 patients in this study, 36 were men and 8 were women. The age of the patients ranged from 36 to 91 years, with an average of 67.1 years at the time of diagnosis. Thirty-nine of them (89%) were smokers, and 34 (77%) were heavy smokers (>20 pack-year). Five patients had pathological stages IA, 9 had IB, 10 had IIB, 11 had IIIA, 6 had IIIB, and 3 had IV. CT features The frequency of thin-section CT findings in all lung PC patients is summarized in Table 1. Central low attenuation/cavity (40/44, 91 %), some irregular margin (27/44, 61%), chest wall and/or mediastinal invasion (26/44, 59%), and pulmonary emphysema (30/44, 68%) was frequently observed on thin-section CT (Fig. 1-3). The majority of the central low attenuation/cavity were massive (>25% of the lesion) (27/44, 61%). Interobserver agreement (# value) for the thin-section CT findings was excellent ( ). TdTs (n=8) ranged from 53 to 139 days, with a mean of 86.7 days. Correlation clinical /CT features with prognosis Univariate analysis of prognostic factors influencing overall and diseasefree survival is summarized in Table 2. Massive central low attenuation and/or cavity on CT and advanced stage (stage III-IV) predicted poorer overall survival (p<.05). Massive central low attenuation and/or cavity on CT, lymph node metastasis, and advanced stage (stage III-IV) predicted poorer disease-free survival (p<.05). Page 3 of 17

4 Multivariate analysis of prognostic factors influencing overall and diseasefree survival is summarized in Table 3. Massive central low attenuation/ cavity on CT indicating necrosis was the only significant independent factor for prognosis (p<.05; Fig. 4 & 5). Images for this section: Table 1: Thin-section CT findings of 44 patients with lung PC. Page 4 of 17

5 Fig. 1: 63-year-old man. Liver metastasis appeared 7 months after surgery, and the patient died of disease 9 months after surgery. Thin-section CT shows a grossly irregular nodule with centrilobular emphysema (a). Central low attenuation indicating necrosis is also seen within the tumor (b). A low-power view of the histologic specimen shows extensive necrosis in the central portion of the tumor (c). A high-power view shows predominantly atypical multinucleated giant cells (d). Page 5 of 17

6 Fig. 2: 60-year-old man. The patient was alive without evidence of recurrence at the 9- year follow-up. Thin-section CT images show a mass with some irregular undulation (a) and chest wall invasion (b). Page 6 of 17

7 Fig. 3: 76-year-old woman. Lung metastasis appeared 7 months after surgery, and the patient died of disease 19 months after surgery. Thin-section CT shows a massive necrotic cavity within the mass. Page 7 of 17

8 Table 2: Univariate analysis of prognostic factors influencing overall and disease-free survival. Page 8 of 17

9 Table 3: Multivariate analysis of prognostic factors influencing overall and disease-free survival. Page 9 of 17

10 Fig. 4: Overall survival according to massive central low attenuation/cavity. Page 10 of 17

11 Fig. 5: Disease-free survival according to massive central low attenuation/cavity. Page 11 of 17

12 Conclusion Discussion As lung PC is a rare type of lung tumor, literature on its clinical features is still limited. However, some unique clinical features of lung PC have been reported [1-5]. It shows prevalence among male smokers who have a history of heavy tobacco consumption. Similarly, the male predominance (4.5:1) and clear association with smoking habit (89% had a history of smoking, and the majority were heavy smokers) were recognized in this study. Kim TH et al. retrospectively evaluated the CT features in 10 patients with lung PC, and reported that lung PC preferentially manifest as large peripheral lung neoplasms with a central low attenuation area (80%) and frequently invade the pleura/chest wall (70%) [6]. Kim TS et al. assessed the CT features of surgically resected lung PC in 30 patients, and central low attenuation/cavity was observed in 50% of their series [7]. In our 44 cases, low attenuation/cavity and chest wall/mediastinal invasion were observed in 90% and 59%, and these results generally concur with previous reports. Tumor doubling time of the lung PC was shorter than that of the common type of lung cancer [8]. Sarcomatoid elements have a high proliferative activity (MIB-1 index) and, which is believed to be the cause of rapid growth [9]. In the pathologic specimens of lung PC, massive central low attenuation and/or cavity on CT was roughly corresponded to areas of ischemic necrosis. We speculate that rapid growth leads to inadequate blood supply, resulting in ischemic changes. Massive central low attenuation and/or cavity on CT was the only significant independent factor for prognosis (p<.05); pathological stage were not significant predictors. Surgical resection alone is therefore insufficient in cases with this finding on CT even when the tumor stage is low, and systemic therapy needs to be explored. Massive central low attenuation and/ or cavity on CT may help in deciding the therapeutic strategy of the lung PC patients. Conclusion Massive central low attenuation and/or cavity on thin-section CT was the only predictor for the poor prognosis of the lung PC. Images for this section: Page 12 of 17

13 Fig. 1: 63-year-old man. Liver metastasis appeared 7 months after surgery, and the patient died of disease 9 months after surgery. Thin-section CT shows a grossly irregular nodule with centrilobular emphysema (a). Central low attenuation indicating necrosis is also seen within the tumor (b). A low-power view of the histologic specimen shows extensive necrosis in the central portion of the tumor (c). A high-power view shows predominantly atypical multinucleated giant cells (d). Page 13 of 17

14 Table 3: Multivariate analysis of prognostic factors influencing overall and disease-free survival. Page 14 of 17

15 Fig. 4: Overall survival according to massive central low attenuation/cavity. Page 15 of 17

16 Fig. 5: Disease-free survival according to massive central low attenuation/cavity. Page 16 of 17

17 Personal information References 1. Corrin B, Chang YL, Rossi G, et al: Sarcomatoid carcinoma. In Travis WD, Brambilla E, Müller-Hermelink HK, Harris CC, ed. World health organization classification of tumors. Pathology and genetics of tumours of the lung, pleura, thymus and heart. Lyon, IARC Press, 2004; Chang YL, Lee YC, Shih JY, Wu CT. Pulmonary pleomorphic (spindle) cell carcinoma: peculiar clinicopathologic manifestations different from ordinary nonsmall cell carcinoma. Lung Cancer 2001; 34: Fishback NF, Travis WD, Moran CA, Guinee DG Jr, McCarthy WF, Koss MN. Pleomorphic (spindle/giant cell) carcinoma of the lung: a clinicopathologic correlation of 78 cases. Cancer 1994; 73: Rossi G, Cavazza A, Sturm N, et al. Pulmonary carcinomas with pleomorphic, sarcomatoid, or sarcomatous elements: a clinicopathologic and immunohistochemical study of 75 cases. Am J Surg Pathol 2003; 27: Nakajima M, Kasai T, Hashimoto H, Iwata Y, Manabe H. Sarcomatoid carcinoma of the lung: a clinicopathologic study of 37 cases. Cancer 1999; 86: Kim TH, Kim SJ, Ryu YH, et al. Pleomorphic carcinoma of lung: comparison of CT features and pathologic findings. Radiology 2004; 232: Kim TS, Han J, Lee KS, et al. CT finding of surgically resected pleomorphic carcinoma of the lung in 30 patients. AJR 2005; 185: Detterbeck FC, Gibson CJ. Turning gray: the natural history of lung cancer over time. J Thoracic Oncol 2008; 3: Fujioka S, Nakamura H, Adachi Y, et al. Pleomorphic carcinoma of the lung in which the sarcomatous element grew rapidly: a case report. Ann Thoracic Cardiovasc Surg 2009; 15: Page 17 of 17