Ann Thorac Surg 2006;81:304
© 2006 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
Melvyn Goldberg, MD, FRCSC
Division of Thoracic Surgical Oncology, Fox Chase Cancer Center, 333 Cottman Ave C312, Philadelphia, PA 19111
(Email: m_goldberg{at}fccc.edu).
Enatsu and colleagues [1] have defined the importance of positive pleural lavage cytology both before and after resection in all stages of surgically resectable nonsmall cell lung cancer. The data clearly supports that those patients with positive cytology (particularly in post-resection specimens) do poorly, with none surviving greater than 4 years.
Recently several groups have identified a survival advantage of as great as 15%, using adjuvant chemotherapy in resected early stage nonsmall cell lung cancer. Possibly many of these patients may have had positive pleural cytology at operation but were not identified, because it is not routinely performed. Possibly the 15% benefit was in this group of patients with more aggressive cell biology. Perhaps not all patients with resected stage I and II nonsmall cell lung cancer require adjuvant chemotherapy, and perhaps pleural cytology is one of the many methods for identifying those patients who are at greater risk for recurrence.
Recently several investigators have demonstrated that in addition to T greater than 3 cm, other descriptors of the tumor play an important role in establishing survival. This includes T less than 1 cm, T between 1 and 2 cm, T between 2 and 3 cm, and in T2 lesions, T greater than 5 cm. In patients with T2 lesions, we now have definitive evidence that those with visceral pleural involvement do less well than those with tumors larger than 3 cm. Perhaps the former group would have positive pleural cytology at resection if it were performed with regularity.
Attempts at correlating certain molecular abnormalities with recurrence and survival is presently being vigorously investigated in all malignancies, and specific treatment programs have been designed in some tumors using this information to target therapy. To date, no confirmed correlation has been established in nonsmall cell lung cancer due to inconsistent results in prospective studies.
It is becoming apparent that within the next decade the staging system that relates to biological activity will have to be revised on a continuing basis. Clinical and pathologic tumor characteristics may direct preoperative and postoperative therapies, and potentially a specific genetic profile of every patient with cancer will identify directed therapies with greater precision, whether it is surgery, radiotherapy, specific systemic chemotherapies, or specific targeted therapies. During the past 30 years we have encountered barriers that have prevented major breakthroughs in the treatment of nonsmall cell lung cancer. With the aid of newer and innovative technologies that explore subcellular mechanisms of tumor behavior, I predict many of these frustrating impediments will be overcome.
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References
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- Enatsu S, Yoshida J, Yokose T, et al. Pleural lavage cytology before and after lung resection in non-small cell lung cancer patients. Ann Thorac Surg 2006;81:298–304..
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