| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Ann Thorac Surg 2004;77:1902-1903
© 2004 The Society of Thoracic Surgeons
Duke University Medical Center Box 3496 Durham, NC 27710, USA
e-mail: damic001{at}mc.duke.edu
Lobectomy has become the standard surgical management for patients with stage I non-small cell lung cancer (NSCLC), based on a report from the Lung Cancer Study Group that demonstrated improved recurrence-free survival, when compared to patients that underwent limited resection [1]. However, there may be patients with compromised pulmonary function in whom the relative benefit of lobectomy versus limited resection is outweighed by the relative risk. Patients in whom the risk-benefit analysis may be particularly important include patients with a higher risk from surgery, such as patients with restrictive lung disease [2], or patients with small peripheral nodules, in whom the relative benefits of lobectomy may not be as significant [3]. The process of preoperative risk stratification, therefore, is central to the choice of procedure [4].
Iizasa and colleagues analyze the prognostic value of preoperative pulmonary function in a series of patients who are treated with lobectomy for stage I non-small cell lung cancer [5]. The potential for this type of risk analysis is considerable: as screening with spiral CT becomes more prevalent, more patients are detected with small peripheral lesions, and the debate regarding the appropriateness of lobectomy versus limited resection has been renewed. In this series, the authors investigate the prognostic value of age, sex, pulmonary function, and tumor size in terms of death from cancer-specific and other causes, in order to examine the role of lobectomy in patients with stage I NSCLC.
The analysis of the appropriateness of lobectomy, versus "lesser" surgical procedures or non-invasive procedures, must consider the risks and benefits of the alternatives. This series analyzes the results of patients who underwent lobectomy and were found on final pathologic evaluation to have stage I (node-negative) disease. Thus, the use of limited resection in this selected population may have been appropriate; however, the status of being node-negative can only be determined after lobectomy has already been performed. The study does not include patients with clinical stage I disease, who may be found to have unsuspected N1 (or N2) disease. In these patients, the use or limited resection would not be curative. Furthermore, of the 402 patients in this series, 27 underwent bilobectomy and 149 (37%) had T2 tumors; thus, the discussion of lesser procedures in this group is unwarranted. The strategy of limited resection, therefore, would only be applicable to a fraction of patients with clinical stage I disease. In the most carefully planned and executed study of limited resection versus lobectomy in this population of patients, lobectomy was superior [1].
The discrepancy between cancer-related and unrelated deaths in this study does not make a compelling case to choose limited resection (or other alternatives) for patients with clinical stage I lung cancer. That this study includes only patients with pathologic node-negative disease assures a superior cancer-specific survival in this population, an assurance that cannot be made preoperatively in clinically staged patients. Thus, analysis of the death rate from conditions unrelated to the primary cancer must take into account the highly selected population, the risk of co-morbidity, and the therapeutic alternatives.
Regarding co-morbidity, there is insufficient evidence to conclude that limited resection is less morbid than lobectomy in patients without severe restrictive disease. The use of wedge resection for patients with small, peripheral tumors may represent a better risk-benefit ratio for a small subgroup of patients; however, this has not yet been demonstrated. In this study, there is no comparison made to limited resection, and the conclusion that lobectomy may not be appropriate is not supported. In fact, there is a great deal of evidence that lobectomy is well tolerated, even in patients with advanced obstructive disease [6, 7].
The most valuable information provided by preoperative pulmonary function tests is the estimation of the risk of complications after resection, including pulmonary and non-pulmonary complications [8]. Except in rare circumstances, pulmonary function testing is not required to select patients for lobectomy, especially upper lobectomy, in contrast to selecting patients for pneumonectomy. The pulmonary function in patients with obstructive pulmonary disease changes minimally after lobectomy [6]. The knowledge that marginal pulmonary function is associated with a higher risk of complications is not sufficient to suggest that lobectomy is not appropriate [9]. The decision to perform lobectomy is based on the curability (clinical stage), options for alternative treatment, the morbidity of those options, and the patients' ability to tolerate the various options.
The authors suggest that patients with impaired pulmonary function have such a high mortality from non-malignant factors that lesser resection should be considered, despite evidence that lobectomy is associated with superior outcome. This study demonstrates that patients with important co-morbidity have inferior overall survival, compared to more healthy patients. There is no basis, however, to conclude that lesser resection (wedge, segment) would confer an improved survival. Until non-invasive alternatives (radiosurgery, radiofrequency ablation) are fully evaluated, lobectomy remains the standard for most patients with clinical stage I lung cancer. Lesser resections may ineffectively detect and treat subclinical nodal disease, in a population least able to tolerate adjuvant chemotherapy and radiation therapy. Furthermore, the majority of patients tolerate lobectomy, despite pulmonary and non-pulmonary co-morbidity. Preoperative pulmonary function tests are invaluable to stratify the risk of postoperative complications, but they are not powerful enough to deny resection in most patients with clinical stage I lung cancer.
References
This article has been cited by other articles:
|
|
 |
|
  T. Iizasa and T. Fujisawa Reply Ann. Thorac. Surg., June 1, 2005; 79(6): 2198 - 2198. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
