Ann Thorac Surg 2009;87:1028-1029. doi:10.1016/j.athoracsur.2009.02.004
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Rodney J. Landreneau, MD
Heart, Lung, and Esophageal Surgical Institute, University of Pittsburgh Medical Center, 5200 Centre Ave, Pittsburgh, PA 15232
(Email: landreneaurj{at}upmc.edu).
Zhu and associates [1] give us a realistic account of the risk and rate of complications related to radiofrequency ablation (RFA) procedures anticipated among clinicians skilled in these approaches. Important messages related to lesion selection for RFA based on size, depth, and the relative relationship of the lesion to pulmonary hilar bronchovascular structures are also illuminated. The authors' commentary on patient selection for this compromise RFA approach to the otherwise resectable peripheral malignant pulmonary nodule is also appreciated.
This brings me to my concerns with the use of RFA among marginal candidates for anatomic pulmonary resection and the growing acceptance of these approaches as more favorable alternatives to sublobar resection among patients with impairment in cardiopulmonary reserve or with lung metastases from remote primary malignancies. The American College of Surgeons Oncology Group (ACOSOG) is presently evaluating the role of RFA for high-risk patients with stage IA non-small cell lung cancers in a phase II trial schema (Z4033). Simultaneously open within ACOSOG is another trial (Z4032) evaluating the outcomes of similarly high-risk patients with stage IA disease randomized to sublobar resection alone or sublobar resection with intraoperative brachytherapy [2]. Primary end points of these trials are related to local control of the patients' tumors and procedurally related morbidity. These are very important studies that will objectively determine some of the outcomes of these approaches to the high-risk patient with resectable early-stage lung cancer. Thoracic surgeons and our medical colleagues should patiently await the results of these trials before making the leap of faith toward applying these image-guided ablative approaches preferentially for the management of such malignant pulmonary parenchymal targets.
Zhu and colleagues' work involves the use of RFA for 100 patients with a variety of malignant lung nodules, only 6 of which were primary lung cancer. In the largest group of patients treated, the pulmonary metastases were from colorectal primary cancers. Patient selection criteria for performing the ablation of these metastatic lesions are not delineated in their work, and one is left to assume that the authors were directing these RFAs to patients with oligometastases with intent to clear all potential disease demonstrable by computed tomography of the chest. Interestingly, this concept of RFA management of metastatic pulmonary lesions appears not to be receiving the same criticism as was directed toward video thoracoscopic approaches to these problems by the thoracic surgical community a decade ago [3].
Many of these radiology "oncologists" call for more liberal use of nonsurgical approaches for the management of stage I non-small cell lung cancer [4]. In this age, pursuant to accurate pathologic staging of lung cancer to avoid under-staging and the potential loss of the therapeutic advantage of adjuvant systemic therapy when more advanced local disease is recognized, I find it troubling that nonsurgical specialists feel comfortable relying on clinical staging paradigms, limited pathologic evaluation, and questionable "objective" lesion clearance for our "early lung cancer" patients [5–7]. To me, this is a step backward in our collective efforts in improving survival with lung cancer.
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References
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- Zhu JC, Yan TD, Glenn D, Morris DL. Radiofrequency ablation of lung tumors: feasibility and safety Ann Thorac Surg 2009;87:1023-1029.[Abstract/Free Full Text]
- Santos R, Colonias A, Parda D, et al. Comparison between sublobar resection and 125Iodine brachytherapy after sublobar resection in high-risk patients with Stage I non-small-cell lung cancer Surgery 2003;134:691-697.[Medline]
- McCormack PM, Bains MS, Begg CB, et al. Role of video-assisted thoracic surgery in the treatment of pulmonary metastases: results of a prospective trial Ann Thorac Surg 1996;62:213-216.[Abstract/Free Full Text]
- Haasbeek CJ, Senan S, Smit EF, Paul MA, Slotman BJ, Lagerwaard FJ. Critical review of nonsurgical treatment options for stage I non-small cell lung cancer Oncologist 2008;13:309-319.[Abstract/Free Full Text]
- Rena O, Oliaro A, Cavallo A, et al. Stage I non-small cell lung carcinoma: really an early stage? Eur J Cardiothorac Surg 2002;21:514-519.[Abstract/Free Full Text]
- Winton T, Livingston R, Johnson D, et al. National Cancer Institute of Canada Clinical Trials GroupNational Cancer Institute of the United States Intergroup JBR.10 Trial Investigators Vinorelbine plus cisplatin vs. observation in resected non-small-cell lung cancer N Engl J Med 2005;352:2589-2597.[Medline]
- Stiles BM, Servais EL, Lee PC, Port JL, Paul S, Altorki NK. Point: clinical stage IA non-small cell lung cancer determined by computed tomography and positron emission tomography is frequently not pathologic IA non-small cell lung cancer: the problem of understaging J Thorac Cardiovasc Surg 2009;137:13-19.[Abstract/Free Full Text]
Related Article
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Radiofrequency Ablation of Lung Tumors: Feasibility and Safety
- Jacqui C. Zhu, Tristan D. Yan, Derek Glenn, and David L. Morris
Ann. Thorac. Surg. 2009 87: 1023-1028.
[Abstract]
[Full Text]
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References