Role of emphysema and airway obstruction in prognosis of lung cancer

doi:10.1016/j.lungcan.2010.05.018

Lung Cancer

Volume 71, Issue 2, February 2011, Pages 182-185

https://doi.org/10.1016/j.lungcan.2010.05.018 Get rights and content

Abstract

Background and objective

It has been reported that the presence of COPD and emphysema is associated with an increased risk of lung cancer, but the prognosis significance of these two conditions is not well known. The aim of our study was to analyze the influence of COPD and emphysema in the prognosis of non-small cell lung cancer (NSCLC).

Methods

Three hundred and fifty-three patients with cytohistologic diagnosis of NSCLC were prospectively collected. The relationship between survival at two years and the following variables: age, sex, smoking habit, comorbid diseases (cardiovascular diseases, previous tumour and COPD), weight loss, presence of emphysema on CT scan, performance status (PS) and treatment, was analyzed. The Kaplan–Meier method and log-rank test were used for survival analysis. A multivariate Cox proportional hazard model, stratified by TNM stage, was used to evaluate prognostic factors.

Results

Emphysema was present in 110 patients, associated with COPD in 78 (70.9%). In univariate analysis, survival decreased with age > 70 years (p = 0.01), presence of emphysema (p = 0.02), weight loss (p = 0.00001), PS ≥ 2 (p = 0.00001) and symptomatic treatment (p = 0.0001). Multivariate analyses identified emphysema (HR = 1.49 (95% CI 1.11–2.01)), PS ≥ 2 (HR = 2.12 (95% CI 1.31–3.38)) and treatment: surgery (HR = 0.3 (95% CI 0.15–0.56)) and chemotherapy (HR = 0.34 (95% CI 0.31–0.57)) as independent prognostic factors.

Conclusion

The presence of emphysema affects the prognostic outcome of patients with non-small cell lung cancer. Emphysema should therefore be considered for prognostic studies on comorbidity.

Introduction

Lung cancer is the leading cause of cancer-related deaths in most developed countries and approximately 80–85% are non-small cell lung cancer (NSCLC) histological subtypes. The presence of other concomitant diseases has been reported in 68% of all lung cancers [1] in a population registry and in 72% of surgical cases, chronic obstructive pulmonary disease (COPD), present in about one half [2], being the most frequent. Emphysema is a major component of COPD, so it could be expected to affect a significant percentage of patients with lung cancer.

In recent years, several studies have focused on the relationship between COPD and its comorbidities. Sufficient epidemiological data are available to assert that COPD patients are at increased risk of developing lung cancer, the association of both diseases being important because of its frequency and also because each disorder carries its own prognostic weight. Thus, several studies have shown that COPD worsened prognosis of early-stage neoplasm [3] but, unfortunately, neither this issue nor emphysema has been studied in depth from this viewpoint.

With this in mind, we performed a study to analyze the influence of COPD and emphysema in the prognosis of non-small cell lung cancer (NSCLC).

Section snippets

Patients

All patients with cytohistologic diagnosis of NSCLC at the University Hospital of the Canary Islands between January 2004 and September 2007 were prospectively included. We used a common database with uniform data collection by a respiratory physician.

Death before treatment due to causes unrelated to neoplastic disease was considered an exclusion criterion.

The multidisciplinary oncology committee, comprised of medical oncologists, radiation oncologists, pulmonologists and thoracic surgeons,

Overall results

During the study period, 359 patients were diagnosed with NSCLC, 6 of whom met the exclusion criterion. The final study sample consisted of 353 patients, 285 men and 58 women, mean age 64.68 years (range: 33–91, SD 11.33). A history of smoking was found in 314 (88.9%), with 59.55 pack/year index (range: 5–130, SD 24.43) and histologic types were distributed as follows: 143 squamous cell carcinoma, 135 adenocarcinoma, 63 undifferentiated large cell carcinoma and 12 others. According to TNM

Discussion

It is well recognized that, for any level of tobacco exposure, patients with COPD have a higher risk of lung cancer and its relationship is severity dependent [7], [8]. Similarly, recent reports have shown that the presence of emphysema on a CT scan was associated with increased frequency of lung cancer [9], [10], but the prognosis significance of these two diseases have not been studied in depth.

In our study we observed two interesting clinical findings. First, emphysema is present in about

Conflicts of interest statement

None declared.

References (21)

A. López-Encuentra
GCCB-S. Comorbidity in operable lung cancer: a multicenter descriptive study on 2992 patients
Lung Cancer
(2002)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)
J. de Torres et al.
Assessing the relationship between lung cancer risk and emphysema detected on low-dose CT of the chest
Chest
(2007)
Y. Sekine et al.
Impact of COPD on pulmonary complications and long-term survival of patients undergoing surgery for NSCLC
Lung Cancer
(2002)
S. Semrau et al.
Impact of comorbidity and age on the outcome of inoperable NSCLC treated with concurrent chemoradiotherapy
Respir Med
(2008)
R.M. Merrill et al.
Conditional survival among patients with carcinoma of the lung
Chest
(1999)
W.L. Read et al.
Differential prognostic impact of comorbidity
J Clin Oncol
(2004)
D.D. Sin et al.
Impact of cancers and cardiovascular diseases in chronic obstructive pulmonary diseases
Curr Opin Pulm Med
(2008)
R.A. Pauwels et al.
GOLD Scientific Committee. Global strategy for diagnosis, management and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary
Am J Respir Crit Care Med
(2001)
National Emphysema Treatment Trial. [Internet]. Available from:...

There are more references available in the full text version of this article.

Cited by (46)

Emphysema – The review of radiological presentation and its clinical impact in the LDCT screening era
2020, Clinical Imaging
Citation Excerpt :
They stated, that if the patients in the Pamplona International Early Lung Cancer Detection Program (P-IELCAP) and the Pittsburgh Lung Screening Study (PLuSS) were included in screening trial based on NLST criteria and/or evidence of emphysema on baseline LDCT - 88% and 95% of incident lung cancers could be detected despite the reduction of the screening cohort by 48% and 27% respectively [26]. Presence of lung emphysema on LDCT image is related with worse survival outcome of lung cancer patients [55–58]. Lung tumors arising in emphysematous lung and in patients with COPD are known to be more aggressive due to specific tumor microenvironment and biology [31,59].
Emphysema is one of three main lung pathologies in Chronic Obstructive Pulmonary Disease, along with chronic bronchitis and small airway obstruction. The diagnosis is based on detection of low attenuation areas in lung tissue on chest Computed Tomography, either visual by a radiologist, or automatic by the applied Computed Tomography software. Results of the studies on the association between emphysema and lung cancer incidence are mixed. Many studies have demonstrated, that chronic lung diseases, like Chronic Obstructive Pulmonary Disease, are associated with lung cancer morbidity. There is also evidence, that emphysema can be related with worse prognosis in patients with detected lung cancer. In this review article we aim to summarize current knowledge about emphysema detection and evaluation on Computed Tomography, both quantitative and qualitative. We also summarize current data on correlation between emphysema and lung cancer, as well as its potential use in selecting patients, who would most benefit from lung cancer screening.
Relationship and prognostic significance between preoperative serum albumin to globulin ratio and CT features of non-small cell lung cancer
2020, European Journal of Radiology
Citation Excerpt :
Previous studies indicated that tumor disappearance rate (TDR) was related to survival in lung cancer [5]. Recent studies have reported the importance of CT-diagnosed emphysema in NSCLC patients, due to coexisting emphysema was associated with the prognostic outcome of NSCLC patients [6,7]. However, the clinically indispensable clinicopathological or hematological predictors in NSCLC studies have not taken the CT features into account, and the prognostic values of CT features needed to be improved further.
This study was conducted to assess the relationship and prognostic significance between preoperative serum albumin to globulin ratio (AGR) and high-resolution computed tomography (HRCT) features of non-small cell lung cancer (NSCLC).
Demographic parameters, laboratory values including AGR and other clinical variables were evaluated in 180 patients with NSCLC, and 72 of these patients had results of radiology parameters detected with HRCT [including emphysema, tumor disappearance rate (TDR), CT values and CT enhanced values of the tumor mass] were assessed for survival analyses. The 72 patients were divided into two groups: normal lung group and emphysema group. The discriminatory values for AGR between these two groups were assessed by Mann–Whitney U test The relationship between TDR and AGR in NSCLC patients was evaluated by Pearson correlation analysis.
In multivariate analysis, TDR (p = 0.033), AGR (p = 0.038), emphysema (p = 0.009), and N stage (P = 0.026) were independent predictors of overall survival (OS). AGR was higher in NSCLC patients without emphysema than NSCLC patients with emphysema (z = −2.979, P = 0.003). TDR demonstrated that there was a positive relationship with AGR (r = 0.307, p = 0.009). A nomogram with AGR, TDR, emphysema, and N stage was established to predict 5-year survival.
There is a relationship between CT features and AGR in NSCLC. The integrative nomogram combined with CT images, clinical and hematologic features improved survival prediction in NSCLC patients, which offers a non-invasive, comprehensive, and convenient evaluation for individualized management of NSCLC patients.
Regional Emphysema Score Predicting Overall Survival, Quality of Life, and Pulmonary Function Recovery in Early-Stage Lung Cancer Patients
2017, Journal of Thoracic Oncology
Citation Excerpt :
To date, much attention has been focused on the difference in prognosis between lung cancer arising in emphysematous and nonemphysematous lungs.7 Several studies6,8,20 reported an association between the presence of emphysema and lung cancer mortality but other studies9,21,22 did not support such association after controlling for patient age, sex, smoking history, and cancer stage. In these previous studies, quantification of emphysema was based on whole lung evaluation, without accounting for the regional distribution of emphysema.
Pulmonary emphysema is a frequent comorbidity in lung cancer, but its role in tumor prognosis remains obscure. Our aim was to evaluate the impact of the regional emphysema score (RES) on a patient’s overall survival, quality of life (QOL), and recovery of pulmonary function in stage I to II lung cancer.
Between 1997 and 2009, a total of 1073 patients were identified and divided into two surgical groups—cancer in the emphysematous (group 1 [n = 565]) and nonemphysematous (group 2 [n = 435]) regions—and one nonsurgical group (group 3 [n = 73]). RES was derived from the emphysematous region and categorized as mild (≤5%), moderate (6%–24%), or severe (25%–60%).
In group 1, patients with a moderate or severe RES experienced slight decreases in postoperative forced expiratory volume in 1 second, but increases in the ratio of forced expiratory volume in 1 second to forced vital capacity compared with those with a mild RES (p < 0.01); however, this correlation was not observed in group 2. Posttreatment QOL was lower in patients with higher RESs in all groups, mainly owing to dyspnea (p < 0.05). Cox regression analysis revealed that patients with a higher RES had significantly poorer survival in both surgical groups, with adjusted hazard ratios of 1.41 and 1.43 for a moderate RES and 1.63 and 2.04 for a severe RES, respectively; however, this association was insignificant in the nonsurgical group (adjusted hazard ratio of 0.99 for a moderate or severe RES).
In surgically treated patients with cancer in the emphysematous region, RES is associated with postoperative changes in lung function. RES is also predictive of posttreatment QOL related to dyspnea in early-stage lung cancer. In both surgical groups, RES is an independent predictor of survival.
Hypothesized Explanations for the Observed Lung Cancer Survival Benefit Among Hispanics/Latinos in the United States
2023, Journal of Racial and Ethnic Health Disparities
Lobar emphysema ratio of more than 1% in the lobe with lung cancer as poor predictor for recurrence and overall survival in patients with stage I non-small cell lung cancer
2023, PLoS ONE
The association of chest computed tomography-defined visual emphysema and prognosis in patients with nonsmall cell lung cancer
2023, ERJ Open Research

View all citing articles on Scopus

¹: C/ Ramón y Cajal, 31-5° izq, 38009 Santa Cruz de Tenerife, Spain.

²: C/ Sabino Berthelot, 16 5° izq, 38003 Santa Cruz de Tenerife, Spain.

³: C/ San Juan Bautista, 19 portal A 1° dcha, 38001 Santa Cruz de Tenerife, Spain.

⁴: C/ S. Juan Bautista. 19 portal A 1° dcha, 38001 Santa Cruz de Tenerife, Spain.

⁵: C/ Real Orotava, 164 A, 38360 Ravelo-El Sauzal, Santa Cruz de Tenerife, Spain.

View full text

Role of emphysema and airway obstruction in prognosis of lung cancer

Abstract

Background and objective

Methods

Results

Conclusion

Introduction

Section snippets

Patients

Overall results

Discussion

Conflicts of interest statement

Lung Cancer

J Chronic Dis

Chest

Lung Cancer

Respir Med

Chest

Differential prognostic impact of comorbidity

J Clin Oncol

Impact of cancers and cardiovascular diseases in chronic obstructive pulmonary diseases

Curr Opin Pulm Med

GOLD Scientific Committee. Global strategy for diagnosis, management and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop summary

Am J Respir Crit Care Med