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Ann Thorac Surg 1999;67:1540-1541
© 1999 The Society of Thoracic Surgeons
a The Cardio-Thoracic Surgical Group, P.A., 185 Livingston Ave, New Brunswick, NJ 08901, USA
To the Editor
Tsubota and associates’ recent, excellent paper is further evidence that lung cancer survival is similar whether limited resection or lobectomy is performed for lesions less than 2 cm [1]. There is a continuously growing literature supporting that concept.
Doctor Ginsberg’s dissenting commentary is more intuitive than scientific and seems to rely upon the evaluation of the Lung Cancer Study Group [2]. Unfortunately, that study was problematic and never genuinely fulfilled the basic criteria necessary to qualify it for a valid prospective randomized trial. Moreover, two very respected and senior thoracic surgeons, Drs. Benfield and Peters, in their respective commentaries, were critical of the findings of this earlier study [2] and could not accept the conclusions.
Presently, there is no scientific evidence confirming a difference in survival between limited resection and lobectomy for lesions less than 2 cm. In fact, numerous contemporary publications confirm a similar survival. Even older publications, at a time when nodes were not examined, computed tomographic scans were not available to demonstrate other smaller concurrent lesions, and tumors larger than 2 cm were commonly excised by limited resection, have reported similar survivals between limited and radical resections.
It is becoming very apparent that carcinoma of the lung is a systemic, biologic problem that cannot always be controlled by simple, anatomic methods. By definition, after complete removal of a single, isolated tumor, that particular tumor cannot recur. It has been totally removed. To label other new lesions as a recurrence is bad semantics. Some lung cancers are multifocal, early metastasizing lesions that can have microscopic and submicroscopic foci that cannot be detected by our current crude and insensitive diagnostic tests. Nevertheless, we continue to adhere to late-19th-century principles that maintain that if the tumor cannot be palpated or visualized, it is not there. As these microscopic tumors continue to grow and, eventually, can be seen and even palpated, they should not be considered recurrences. Instead, these newly observable lesions are most likely the natural progression of tumor foci that were already present at the initial diagnosis, but could not be detected or identified, at that specific time, by our current methods.
Doctor Ginsberg continues to refer inappropriately to a fourfold recurrence rate instead of a fourfold tumor progression rate between limited resection and lobectomy. Nevertheless, putting semantics aside, survival still remains the same. Massard and coworkers [3] reported a sevenfold recurrence (or progression) rate between bilobectomy and pneumonectomy, yet survival was the same. We have randomly sectioned some of the normal-appearing pulmonary parenchyma of our curatively resected malignancies and have found microscopic foci of tumor at far distances from the primary lesion in stage 1 disease. These lesions could not be appreciated preoperatively and would not have been found without very carefully searching for them postoperatively. One must be suspicious that similar microscopic tumor foci could be present in the other nonresected lobes. Limited resection when compared with lobectomy conserves vital pulmonary tissue, has a decreased surgical mortality, reduced complication rate, and a similar survival for carcinoma. There seems little scientific justification for always advocating a radical resection when a lesser resection can be accomplished successfully.
Despite using our present inviolate, traditional oncologic principles and surgical techniques, carcinoma of the lung has ascended to the inauspicious position of the number one neoplastic killer for men and women. Our present oncologic approaches have been failing our patients. Possibly, the time has come to revisit and even revise some of these revered, but antiquated, and probably invalid, oncologic principles. We should try to evolve new surgical methods that, hopefully, could improve our less than satisfactory outcomes for carcinoma of the lung. In 1931, Dr Mayo concluded, "Scientific truth, which I formerly thought of as fixed, is changeable. Truth is a constant variable."
To continue to preach that lobectomy must always be performed and that there is never an indication for a limited resection as an innately curative procedure seems more intuitive than scientific as we are beginning to discover that cure depends less on technique than the biology of the tumor [4].
References
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