Diagnosis of lung cancer: a necropsy-based study of 128 cases (1997-2016)

Our plain-English summary of Diagnosis of lung cancer: a necropsy-based study of 128 cases (1997-2016), by P.G. Barbieri, D. Mirabelli (Tumori, 2021).

The study

• Authors: P.G. Barbieri, D. Mirabelli
• Journal: Tumori
• Published: 2021;107(3):226-230
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: The diagnosis of lung cancer (LC) may be difficult to make in the elderly. We report on the diagnostic elements available in life in an LC necropsy case series of asbestos-exposed workers and describe the frequency of non-neoplastic asbestos-related diseases as biological exposure indices.

Methods: We reviewed pathologic and clinical records of an unselected series of autopsies (1997-2016) in patients with LC employed in the Monfalcone shipyards. We assessed the consistency with autopsy results of diagnoses based on, respectively, radiologic, cytologic, and histologic findings.

Results: Data on 128 autopsy-confirmed LC cases were available; in life, 119 had been diagnosed as LC. Among these, 49 had histologic confirmation of diagnosis (17 with immunophenotyping); histology had been negative in 4. Cytology had been the main positive finding and the basis for diagnosis in 24 cases, but had been negative in 13. Chest computed tomography had been the basis for diagnosis in 45; in 18 cases, it had been negative. Nine patients had received a diagnosis different from LC, among whom 4 had been suspected to have malignant pleural mesothelioma by chest computed tomography. Pleural plaques were found in 124 and histologic asbestosis in 46 cases.

Conclusions: Autopsies confirmed all LC diagnoses received in life, including 46 that would have been considered only possible LC based on clinical workup. The overall survival in this case series was poor. The high prevalence of pleural plaques and asbestosis suggest severity of asbestos exposures.

In plain English

The authors reviewed records of 128 autopsies (1997 to 2016) of men in Italy's Gorizia and Udine provinces who had worked at the Monfalcone shipyards and had lung cancer at autopsy. All were considered exposed to asbestos at work. Fiber types were not reported. The authors checked how each diagnosis had been reached in life. In 119 cases (93.0%), lung cancer had been diagnosed before death, and autopsy confirmed all 119. Of these, 46 rested on imaging alone. The other 9 were found only at autopsy, including 4 thought in life to have malignant pleural mesothelioma. Median survival after diagnosis was 3 months, and 23% lived at least 1 year. Pleural plaques were found in 124 men and histologic asbestosis in 46. The authors concluded that a radiologist's reading of chest CT as showing primary lung malignancy was a strong predictor of diagnosis. They noted that the series most likely included only part of these workers' lung cancer cases. A crude estimate, valid only if their assumptions held, put the share autopsied at about 20% to 40%, creating potential for selection.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case series: review of autopsy reports and clinical records of lung cancer cases confirmed at autopsy
• Who was studied: 128 men (all male) who had worked at the Monfalcone shipyards, lived in Gorizia and Udine provinces, Italy, and had lung cancer at autopsy from 1997 to 2016. These were drawn from 146 such autopsies; 128 had complete clinical documents.
• Exposure: Occupational asbestos exposure as shipyard workers. Fiber types and doses were not reported.
• Main results:
  • Lung cancer had been diagnosed in life in 119 of 128 cases (93.0%), and autopsy confirmed all 119 of these diagnoses.
  • Basis of the in-life diagnosis: clinical or radiologic in 46 cases (45 by chest CT, 1 by chest radiograph), cytologic in 24, and histologic in the remaining 49.
  • By level of certainty in life: 65 definite, 8 probable, and 46 possible lung cancer (suspected only by imaging).
  • Sensitivity of the in-life diagnosis was 93.0% (CI 88.6 to 97.4) counting all levels of evidence, and 57.0% (CI 48.4 to 65.6) counting only cases with microscopic confirmation.
  • Of the 9 cases diagnosed with lung cancer only at autopsy, 4 had been diagnosed in life with malignant pleural mesothelioma (3 possible, 1 probable), mainly by CT imaging.
  • Among the 128 cases, 23% survived at least 1 year after diagnosis and 12% at least 2 years. Median survival was 3 months.
  • Younger age and surgery with radical intent predicted longer survival. Median survival was 26 months (95% CI 9 to 58) after lobectomy or pneumonectomy versus 2 months (2 to 4) with no surgery (p less than 0.001). It was 5 months under age 75 versus 2 months over 75 (p 0.008).
  • The most frequent cell type at autopsy was adenocarcinoma (43 cases, 33.6%), followed by squamous cell carcinoma (38, 29.7%).
  • At autopsy, bilateral pleural plaques were found in 124 (96.8%) and histologic asbestosis in 46 (36%). In life, asbestosis had been diagnosed in only 8.
• The authors' conclusion: The authors concluded that a radiologist's assessment of chest CT as showing primary lung malignancy is a strong predictor of a lung cancer diagnosis. They saw this as relevant because many patients are too old for bronchoscopy. They also considered the high prevalence of pleural plaques and asbestosis an index of the frequency and intensity of the workers' asbestos exposures.
• Limitations the authors state:
  • The authors stated that the series most likely included only part of all lung cancer cases among Monfalcone shipyard workers during the study period.
  • Applying lung cancer to mesothelioma ratios from other studies, the authors made crude estimates. If those assumptions hold, only about 20% to 40% of all lung cancer cases were reported to the prosecution office and autopsied. This would reduce study size and power and create potential for selection of cases.
  • Underreporting was likely because occupational histories are not routinely collected for lung cancer cases.
  • The authors could not tell whether the poorer survival compared with national data reflected selection bias or chance.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Lung cancer.

Medical terms in this study, explained in our Lexicon: Lung Cancer, Autopsy, Histology, Cytology, Pleural Mesothelioma, Pleural Plaques, Overall Survival, Asbestos Exposure.

Related studies

• On the diagnosis of malignant pleural mesothelioma: A necropsy-based study of 171 cases (1997-2016) — P.G. Barbieri, D. Mirabelli, et al. (2019)
• Accuracy of pleural biopsy for the diagnosis of histologic subtype of malignant pleural mesothelioma: Necropsy-based study of 134 cases — P.G. Barbieri, D. Consonni, et al. (2022)
• Pleural plaques as risk indicators for malignant pleural mesothelioma: a necropsy-based study — C. Bianchi, A. Brollo, et al. (1997)
• On the diagnosis of malignant pleural mesothelioma: a necropsy-based study of 171 cases (1997-2016) — P.G. Barbieri (2019)
• Pleural plaques and exposure to mineral fibres in a male urban necropsy population — A. Karjalainen, P.J. Karhunen, et al. (1994)
• Asbestos bodies and pleural plaques in human lungs at necropsy — I. Hägerstrand, B. Seifert (1973)

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