Ann Thorac Surg 2005;80:1979
© 2005 The Society of Thoracic Surgeons
Correspondence
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Hiroyuki Sakurai, MD,
Yoh Dobashi, MD,
Masahiko Matsumoto, MD, PhD
Second Department of Surgery, Faculty of Medicine, University of Yamanashi, 1110 Shimokato, Tamaho-cho, Nakakoma-gun Yamanashi, 409-3898 Japan
(Email: sakuraihm{at}ybb.ne.jp).
To the Editor:
We thank Dr Pramesh and colleagues [1] for their constructive comments on our report [2] and the Editor for giving us the opportunity to reply.
The definition for bronchioloalveolar carcinoma (BAC) of the lung was revised according to the most recent World Health Organization histologic classification in 1999 (3rd ed.) [3]. Bronchioloalveolar carcinoma is clearly defined as an adenocarcinoma with a pure bronchioloalveolar growth pattern and no evidence of stromal, vascular, or pleural invasion. Therefore, BAC should be considered a "non-invasive" rather than "low-invasive" adenocarcinoma. With regard to the extent of surgical resection, fundamentally, a lobectomy and mediastinohilar lymph node dissection for radical resection should be indicated only for tumors with a possible risk of invasion. However, a lobectomy has been considered the operation of choice in the treatment of T1 nonsmall cell lung cancer since the prospective trial carried out by the Lung Cancer Study Group, which focused solely on T1 tumor and did not consider pathological aspects such as invasive growth within the nodule [3]. In patients with BAC, (ie, adenocarcinoma with no invasion), a limited resection such as wedge/segmentectomy, may be sufficiently curative if the surgical margin is reasonable (ie, is at least 2 cm of normal lung parenchyma away from a tumor).
It is important to consider how precisely a pathologic diagnosis of BAC can be made. Because the definition of BAC requires no evidence of invasive components within the entire nodule, BAC cannot be diagnosed based on small biopsied specimens. Therefore, for BAC lesions, local excision is likely to offer both pathologic diagnostic and therapeutic benefits. In addition, unless an accurate diagnosis of BAC with no invasion is available intraoperatively or preoperatively, it can have little impact on the surgical procedure, and lobectomy with mediastinohilar lymph node dissection is the standard form of resection that should be performed whenever possible for T1 nonsmall cell lung cancer [4]. As recently reported, the possibility of an accurate intraoperative or preoperative diagnosis of BAC has been suggested based on the close relationship between BAC and the appearance of ground-glass opacity on high-resolution computed tomographic scan [5], or a confident pathologic diagnosis based on intraoperative frozen section [6]. Further research on whether a precise diagnosis of BAC can be made intraoperatively or preoperatively is needed before such propositions can be confirmed.
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References
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- Pramesh CS, Mistry RC, Agarwal J. How should bronchioloalveolar carcinoma of the lung 3 centimeters or less be treated? (letter) Ann Thorac Surg 2005;80:1978.[Free Full Text]
- Sakurai H, Dobashi Y, Mizutani E, et al. Bronchioloalveolar carcinoma of the lung 3 centimeters or less in diametera prognostic assessment. Ann Thorac Surg 2004;78:1728-1733.[Abstract/Free Full Text]
- Travis WD, Colby TV, Corrin B, Shimosato Y, Brambilla E, World Health Organization International Histological Classification of Tumors Histological typing of lung and pleural tumors.. 3rd ed. Berlin: Springer, Inc; 1999.
- Ginsberg RJ, Rubinstein LV, Lung Cancer Study Group Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer Ann Thorac Surg 1995;60:615-622.[Abstract/Free Full Text]
- Asamura H, Suzuki K, Watanabe S, Matsuno Y, Maeshima A, Tsuchiya R. A clinicopathological study of resected subcentimeter lung cancersa favorable prognosis for ground glass opacity lesions. Ann Thorac Surg 2003;76:1016-1022.[Abstract/Free Full Text]
- Marchevsky AM, Changsri C, Gupta I, Fuller C, Houck W, McKenna RJ. Frozen section diagnoses of small pulmonary nodulesaccuracy and clinical implications. Ann Thorac Surg 2004;78:1755-1760.[Abstract/Free Full Text]
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