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• W2006264794 abstract "To the Editor: Lung cancer is the leading cause of cancer-related death in bothmen and women, and non-small cell histology accounts for 80 to 85% ofcases.1Parker SL Tong T Bolden S et al.Cancer statistics, 1997.CA Cancer J Clin. 1997; 47: 5-27Crossref PubMed Scopus (2338) Google Scholar The staging of non-small cell lung cancer (NSCLC)provides the opportunity to classify the anatomic extent of the diseaseand to determine treatment as well as to define prognoses. The stagingsystem for NSCLC has evolved over the past 26 years in an effort tobetter serve these principles. In 1974, the American Joint Committee for Cancer Staging (AJCC) formedthe Task Force on Carcinoma of the Lung and issued recommendations forthe staging of NSCLC.2Mountain CF Carr DT Anderson WAD A System for the clinical staging of lung cancer.AJR Am J Roentgenol. 1974; 120: 130-138Crossref Scopus (230) Google Scholar In 1985, the AJCC combined with the, Union Internationale Contre Cancer and with Japanese and Germanrepresentatives to propose a revised international staging system forlung cancer.3Mountain CF A new international staging system for lung cancer.Chest. 1986; 89: 225S-231SAbstract Full Text Full Text PDF PubMed Google Scholar This was further revised in1997.4Mountain CF Revisions in the international system for staging lung cancer.Chest. 1997; 111: 1710-1717Abstract Full Text Full Text PDF PubMed Scopus (4528) Google Scholar Malignant pleural effusion was considered a T4 (stage IIIB) lesion inthe 1985 revision, thus implying that patients with malignant pleuraleffusion had a more favorable prognosis than did patients with M1(stage IV) disease. The 1997 revision did not alter that status. However, Naruke et al5Naruke T Tsuchiya R Kondo H et al.Implications of staging in lung cancer.Chest. 1997; 112: 242S-248SAbstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar showed that the survival rate ofpatients with stage IIIB disease who have malignant effusions isconsiderably worse than those with stage IIIB disease who do not havemalignant effusions. The 5-year survival rate for patients with stage, IIIB disease who do not have effusions was 45.4% vs 15.9% for thosepatients who have malignant pleural effusions. Naruke etal5Naruke T Tsuchiya R Kondo H et al.Implications of staging in lung cancer.Chest. 1997; 112: 242S-248SAbstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar also reported a 42.5% 5-year survival rate forpatients with pleural effusions that were deemed nonmalignant. Whilethese numbers seem a little high, they nonetheless reflect the factthat patients with malignant pleural effusions are prognosticallysimilar to patients with stage IV disease. The above data suggest a difference between malignant and nonmalignantpleural effusions associated with NSCLC. A pleural effusion isconsidered malignant if the findings of cytologic testing are positiveor, in the event of negative results of cytologic testing, the fluid isexudative and/or bloody. In rare instances, pleural effusionswill be transudative and nonbloody, will have negative results ofcytologic testing, and can be considered as reactive, inwhich case the tumor stage would be T1–3. Sugiura et al6Sugiura S Ando Y Minami H et al.Prognostic value of pleural effusion in patients with non-small lung cancer.Clin Cancer Res. 1997; 3: 47-50PubMed Google Scholarcompared the survival of 197 patients with stage IIIB disease, with andwithout pleural effusion, and stage IV disease. They found that themedian survival time for patients with stage IIIB disease who hadpleural effusions was comparable to that of patients with stage IVdisease (7.5 and 5.5 months, respectively) and was significantly worsethan that for patients with stage IIIB disease who did not have pleuraleffusions (median survival time, 15.3 months). Among the patients withpleural effusions, there was no difference in survival time whether theresults of fluid cytology testing were positive or negative, providedthe latter patients had either bloody and/or exudative fluid that wasclinically judged to be the result of the underlying lungcancer. Our experience at the Scott & White Clinic is similar. Wereviewed tumor registry data for the preceding 5 years (1993 to 1998). A chart review of all patients coded as stage IIIB and IV wasperformed. Stage IIIB patients with clearly defined pleural effusionsthat were either cytologically positive or were bloody, exudative, andassociated with an underlying histology-documented NSCLC were evaluatedseparately. There were 120 patients with stage IIIB disease who met thecriteria and were considered evaluable for survival (patients withoutpleural effusions, 83 patients; and patients with pleural effusions, 37patients). The median survival time for the patients without pleuraleffusions was 12 months (range, 1 to 74 months), while the mediansurvival time for those patients with pleural effusions was 2 months(range, 1 to 17 months) [Fig 1]. Onehundred ninety-two patients with stage IV disease showed a mediansurvival time of 4 months (range, 1 to 41 months) [Fig 2]. While the median survival time forpatients with stage IIIB disease with effusions was less than that forpatients with stage IV disease, the number was small due to manypatients being excluded for not meeting the criterion of malignantpleural effusion. Nonetheless, the survival time paralleled that ofpatients with stage IV disease and was considerably worse than that ofpatients without malignant pleural effusions.Figure 2Kaplan-Meier survival rate by AJCC stage forpatients with stage IV NSCLC.View Large Image Figure ViewerDownload (PPT) Many clinicians caring for lung cancer patients often approach stage, IIIB disease with pleural effusion like stage IV disease and treat thepatient primarily with chemotherapy. Many ongoing clinical trials inpatients with advanced lung cancer include patients with stage IIIBdisease who have malignant effusions and patients with stage IVdisease. Patients with stage IIIB disease without pleural effusions areoften considered for combined modality therapy with chemoradiation. Ina study addressing the 1997 International Staging System, Green etal7Green M Leong S Caio M et al.The 1997 International Staging System for Non-Small Cell Lung Cancer: have all the issues been addressed?.Chest. 1999; 115: 242-248Abstract Full Text Full Text PDF Scopus (58) Google Scholar suggested that it would be more appropriate toclassify patients with malignant pleural effusions as having stage IVdisease rather than stage IIIB disease. I agree with this and would recommend changing the classification ofpatients with malignant pleural effusions. Those patients who haveeither cytologically positive fluid or fluid that is bloody and/orexudative and appears clinically associated with the underlying lungcancer should henceforth be given a distinct classification of stage, IVA. This would more accurately reflect the prognosis of this group ofpatients with NSCLC, would streamline clinical trials, and would maketreatment considerations more consistent. All patients with M1 diseasewould be at stage IVB. Alternatively, malignant pleural effusions couldsimply be included in stage IV disease.. However, the divisioninto A and B would identify the subtle differences between these twogroups, even though survival expectations are comparable. Either way, this would leave patients with T4 lesions without pleural effusion and, N3 nodes in the stage IIIB group, for whom treatment withchemoradiation would be more appropriate." @default.
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• W2006264794 title "Malignant Pleural Effusion in Non-small Cell Lung Cancer—Time for a Stage Revision?" @default.
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