Ann Thorac Surg 1997;63:1450
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Robert J. Ginsberg, MD
Division of Thoracic Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10021
See also page 1441.
Vansteenkiste and associates are to be congratulated on a detailed analysis with relatively long-term follow-up of patients with resected non–small cell lung cancer proving to have N2 disease either preoperatively or at operation. With multivariant analysis techniques, they have confirmed the adverse prognostic factors that so many other authors have also detailed. There is very little new in this article other than the long follow-up and detailed multivariant analysis. Results are similar to those already seen in the literature.
The important message that we can retrieve from this study is that, despite Vansteenkiste and associates' suggestion that operation is "worthwhile" after a negative mediastinoscopy despite positive N2 disease at the time of resection, 70% of such patients were not cured. There is recent evidence in the literature that patients with clinically evident N2 disease treated with induction therapies, either chemotherapy or chemoradiotherapy, followed by operation fare better than those treated with a primary operation. Because clinical staging understages vis-à-vis final pathologic staging, the obvious next step would be to attempt to identify patients with a poor prognosis, eg, those with greater than T1 lesions or clinical N1 disease that may prove to be N2 disease at thoracotomy, and treat these patients with a combined modality approach. As well, there is evidence in the literature that a primary chemoradiotherapy approach without operation yields similar 5-year survivals as the ones reported by Vansteenkiste and associates in this article-and these patients had, for the most part, no clinical evidence of N2 disease at the time before the operation.
For all of the above reasons, the real message we can take from this series of patients is that if N2 disease is discovered at operation, although surgical resection is recommended, the overall results only cure one-third of patients. It is incumbent upon us to develop better methods of identifying "occult" N2 disease before the operation. These patients can then be considered for combined modality therapy, which appears to have a better chance of ultimate cure. In the future, this may include positron emission tomographic scanning, immunohistochemical staining of lymph nodes obtained at mediastinoscopy, and identification of patients with clinical N1 disease who also have a poor prognosis with surgical resection alone and may, indeed, harbor occult N2 disease.
Related Article
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Survival and Prognostic Factors in Resected N2 Non–Small Cell Lung Cancer: A Study of 140 Cases
- Johan F. Vansteenkiste, Paul R. De Leyn, Georges J. Deneffe, Georges Stalpaert, Kris L. Nackaerts, Toni E. Lerut, and Maurits G. Demedts
Ann. Thorac. Surg. 1997 63: 1441-1450.
[Abstract]
[Full Text]
