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Ann Thorac Surg 2001;71:1757-1758
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
Address reprint requests to Dr Putnam, Department of Thoracic and Cardiovascular Surgery, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 445, Houston, TX 77030
e-mail: putnam{at}mdanderson.org
Thoracic surgeons effectively treat complex biologic problems with mechanical interventions. However, most patients with lung cancer have locally advanced or metastatic disease not amenable to surgical therapy, and surgeons treat a minority of lung cancer patients. Accurate clinical staging (cStage) optimizes selection of surgical or other therapy whereas accurate pathologic staging (pStage) optimizes a better understanding of therapy and survival. Without optimal cStage and pStage information, the surgeon’s ability to select or provide the most effective and efficient treatment is limited, inconsistent, and costly.
In this issue of The Annals, Naruke and colleagues [2] present a detailed staging analysis of 3,043 patients with primary carcinoma of the lung who underwent pulmonary resection between 1961 and 1995. The authors have provided survival data based on the cStage and pStage. This study both complements previous investigations [3] and challenges current staging guidelines. Although the length of time during which the cStage data were collected may yield unsuspected biases, the use of lymph node dissection rather than lymph node sampling optimizes pStage accuracy. The detailed description and precise definition of survival based on cStage and pStage (stratified by histology, T status, N status, and M status) aid the physician or the surgeon in selecting the appropriate diagnostic, prognostic, and therapeutic options that may be available [4]. Complete follow-up on all patients was a Herculean accomplishment, and I commend the authors.
Could this study herald the end of the anatomic staging of lung cancer? Although the systematic anatomic staging of lung cancer will continue to play a critical role in treatment of patients for some time to come, significant improvements in postresection survival may occur from various endeavors: earlier detection and treatment, multidisciplinary care, or genetic modulation of the tumor. Characterization of biologic or molecular factors may eventually yield more-accurate staging of lung cancer than current anatomic staging systems allow.
Today, even with more precise anatomic cStage and pStage, our ability to apply it consistently in ways to improve the care (and survival) of our patients remains limited. Many surgeons do not perform a biopsy on any mediastinal lymph nodes at the time of resection. As shown in Naruke and colleagues’ intense, single-institution study, resected patients with pathology-confirmed N2 nodal disease still have a poor survival (pN2, 19.9%; pStage IIIA, 23.6%). More surgery, as the sole therapy or as the initial therapy, will not consistently improve survival in N2-positive patients, but information gained may modify subsequent therapy. Other therapy (and better therapy) will be of greater value than surgery alone in these patients [5]. Heterogeneity of stage IIIA (bulky pretreatment N2 and postresection microscopic N2) may have different treatment ramifications—how should this be staged? Or treated? Small prospective studies have shown an advantage for neoadjuvant therapy in patients with potentially resectable cStage IIIA lung cancer [6, 7]. On the basis of these early encouraging results, a prospective study of chemotherapy and surgery for cStage IB, IIA, IIB, and highly selected IIIA (T3N1) patients is under way [8]. Appropriate selection of patients for treatment demands accurate clinical staging. This multidisciplinary approach is feasible [9] and potentially offers significant advantages to our patients without significantly increasing morbidity [10]. An integrated patient treatment plan established by the thoracic surgeon, the medical oncologist, and the radiation oncologist, before the initiation of treatment, is the standard of care at this institution. This multidisciplinary "think tank" optimizes the contributions of each specialty for patient care and provides a basis for additional multidisciplinary solutions for other lung cancer patients. A foundation of multidisciplinary care will be critical for unemotional discussions of optimal cost-effective care in these patients.
A significant percentage of patients with cStage IA (29.2%) or even pStage IA (21%) do not live for 5 years. Could these patients or tissues be better staged or treated on the basis of nonanatomic (biologic and molecular) characteristics to better distinguish those patients who will or will not survive as predicted after treatment? Do patients with pStage IIA, IIB, and selected IIIA lung cancer have significantly different survival? What will be the optimal treatment of patients with two resectable nodules in a single lobe or a single nodule in two separate lobes? Positron emission tomography may eventually obviate the need for tissue diagnosis of nodal or distant metastases in selected patients. Biomarkers or genetic changes may more accurately characterize the physical, biologic, and metastatic potential of tumors [11]. Small studies have shown the potential for clinical application [12]. Refinements in molecular characterization and rapid clinical applications are needed.
Our current staging system is in transition—both anatomically and biologically. Further refinements in anatomic staging will require much larger patient populations to detect smaller survival differences. Naruke and colleagues have identified an international need to improve lung cancer staging. Prospective data collection and the integration of these data can improve the current and ongoing care of our patients with lung cancer. Collective data may suggest new answers to vexing surgical, medical, or radiation questions. Our multidisciplinary treatment plans require refinements in anatomic staging and will eventually require molecular characterization of this and other cancers. The exclusive use of cStage and pStage anatomic characteristics will gradually decline as molecular staging evolves. This evolution will mark "the end of the beginning" of anatomic lung cancer staging.
"... this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning." [1]
References
This article has been cited by other articles:
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  A. Sayar, A. Turna, O. Solak, A. Kilicgun, N. Urer, and A. Gurses Nonanatomic prognostic factors in resected nonsmall cell lung carcinoma: the importance of perineural invasion as a new prognostic marker Ann. Thorac. Surg., February 1, 2004; 77(2): 421 - 425. [Abstract] [Full Text] [PDF]
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 S. Eggeling, T. Martin, J. Bottger, T. Beinert, and K. Gellert Invasive staging of non-small cell lung cancer - a prospective study Eur. J. Cardiothorac. Surg., November 1, 2002; 22(5): 679 - 684. [Abstract] [Full Text] [PDF]
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