Ann Thorac Surg 2009;88:1111. doi:10.1016/j.athoracsur.2009.06.072
© 2009 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited Commentary
Morihito Okada, MD, PhD
Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima City, 734-8551 Japan
(Email: morihito1217jp{at}aol.com).
The histology of lung cancer has shifted globally toward adenocarcinoma of the peripheral lung, as the frequency of detecting small-sized bronchioloalveolar carcinoma (BAC) has increased. Based on a clinical trial conducted in the late 1980s, lobectomy has become the standard treatment for even small-sized nonsmall cell lung cancer (NSCLC) at a very early stage [1]. Recently, tumors measuring 2 cm or smaller may be indications for sublobar resection, after which lung function may not be impaired and patients may be more likely eligible for curative surgery if a second lung cancer develops [2]. Multicenter studies currently accruing patients (CALGB 140503 in the United States and Canada; JCOG 0802/0804 in Japan) will yield important insights regarding radical sublobar resection.
In this prospective phase II study, Koike and colleagues [3] evaluate sublobar resection for noninvasive BAC diagnosed by intraoperative pathologic examination. The authors demonstrate that wedge resection (ie, segmentectomy only when a tumor is too deep to be completely removed by wedge resection) can be a curative procedure, and that this procedure may be an alternative to standard lobectomy for patients with noninvasive BAC, as determined intraoperatively and by pathologic examination.
Depending on the situation, correct diagnosis of a noninvasive BAC in tiny tumors can be far more difficult when based on intraoperative pathology rather than preoperative radiographic findings, such as high-resolution computed tomographic imaging (HR-CT). The effects of various outcome factors of this study, namely the skill of the pathologist, the cut portion of the tumor, and the definition of noninvasiveness, must be understood.
Segmentectomy and wedge resection are quite different because the former can evaluate hilar (N1) lymph nodes and provide a sufficient surgical margin, although both procedures are collectively included within sublobar (limited) resection. Limited resection can be changed to wedge resection in this study, because the lymph nodes were not assessed. It is important to understand the qualitative difference between the two surgical procedures and to avoid using the term "limited resection," which may cause confusion. In the CALGB 140503 trial, intraoperative confirmation of N0 status by examining nodal levels 4, 7, and 10 on the right side and 5, 6, 7, and 10 on the left side is mandatory. However, wedge resection, which cannot remove or assess hilar and intrapulmonary nodes, is permitted, and thus is inconsistent.
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References
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- Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy vs limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995;60:615-622.[Abstract/Free Full Text]
- Okada M, Koike T, Higashiyama M, Yamato Y, Kodama K, Tsubota N. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study J Thorac Cardiovasc Surg 2006;132:769-775.[Abstract/Free Full Text]
- Koike T, Togashi K, Shirato T, et al. Limited resection for noninvasive bronchioloalveolar carcinoma diagnosed by intraoperative pathologic examination Ann Thorac Surg 2009;88:1106-1111.[Abstract/Free Full Text]
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Limited Resection for Noninvasive Bronchioloalveolar Carcinoma Diagnosed by Intraoperative Pathologic Examination
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Ann. Thorac. Surg. 2009 88: 1106-1111.
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