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Ann Thorac Surg 1995;59:867
© 1995 The Society of Thoracic Surgeons
DR WILLIAM F. SASSER (St. Louis, MO): It is always a disappointment to learn that a patient has a recurrent or new lung cancer after he or she has been disease free for several years. This paper establishes treatment options and survival statistics that are appropriate for these unfortunate patients. I would like to ask Dr Antakli and associates several questions in their management. Because of the role of increasing managed care, guidance as to the appropriate follow-up studies is necessary. Because many of the new growths were established with computed tomographic scans do you suggest periodic computed tomographic scanning of the chest? If so, at what interval do you repeat the scans?
Second, in the study of your patients is there speculation that a program of adjuvant postoperative chemotherapy would decrease the recurrence or the appearance of a new cancer?
The third comment I would make is that cessation of cigarette smoking must be stressed above all measures.
DR ANTAKLI: Thank you, Dr Sasser. Our policy of following up those patients includes chest roentgenogram and physical examination of the patient every 3 months for three occasions, followed by the same every 6 months for two occasions, and then we see the patient yearly for life with chest roentgenograms and physical examination. We use sputum cytology whenever the patient gives us any history of change in the pattern of coughing or sputum production. We tend to use the computed tomographic scan very liberally in case there is any question what the chest roentgenograms might bring.
Regarding the use of chemotherapy in those patients as prevention, there has been a lot of literature recently produced about the use of chemo-prevention in those patients, which involves the use of retinoic acid products to decrease the chance of cancerous changes. The use of chemotherapy per se has not been associated with a decrease in SPLC. We went over this in our series and we have not seen any reduction in development of second primary lung cancer in patients who have received adjuvant chemotherapy in stage I and II.
DR LEWIS WETSTEIN (Freehold, NJ): This is a very difficult clinical problem and unfortunately we are seeing an epidemic of either second primary tumors or recurrences. Of course, the therapeutic approach varies dramatically if the tumor is indeed a second primary versus a recurrence. Moreover, I am extremely uncomfortable when, for example, bilateral lungs are involved simultaneously and the pathology is the same, be it both squamous or adenocarcinoma, and my pathologist tells me regardless they are second primary tumors.
Again, because the therapeutic management is so different depending on the clinical scenario, we have attempted your suggestions. But even if you look at your own criteria for differentiating recurrences or second primary tumors, the parameters are superimposable. The only factor we have not employed is the ploidy issue. Do you believe that this is the definitive answer to this dilemma? More or less, what are the sensitivity and specificity of the ploidy results in distinguishing whether a tumor is a second primary versus a recurrence?
DR ANTAKLI: It is definite; it gives you a definite answer as to the nature of the tumor. We have used it in 1 patient in whom Martini and Melamed's criteria were not conclusive; this particular patient had four synchronous lesions after a resected primary lung cancer and all these lesions had different DNA ploidy signatures, and the pathologist who had done this for us was very confident that each of those lesions was a different tumor, even though the histology was the same in all those lesions.
DR JOHN R. BENFIELD (Sacramento, CA): It may be that our trying to wrestle with the issue of whether a lung cancer is a second primary tumor or not is something that is impossible to ferret out by current techniques. In fact if one looks at lung cancers carefully, at least 50% of them are truly mixed in character; whether a lung cancer is labeled by the pathologist an adenocarcinoma or a squamous cell carcinoma may be a function of how carefully the pathologist has looked at that neoplasm and by what techniques the examination has been done. I think the same is true of the measurement of ploidy. Ploidy is simply a measurement of total DNA content; it is one of the most macroscopic, cellular biology ways of looking at a neoplasm. It may well be that we are being a little simplistic in thinking that the pathologist can tell us what is primary and what is not primary.
The issue is that pulmonary resection of cancer is a local control measure. I agree entirely that one should remove localized second primary neoplasms in the lung. However, I recommend that the resection should be conservative and tissue-sparing whenever it is reasonable to do so. We avoid pneumonectomy and try not to use lobectomy. We prefer segmentectomy as the operation of choice for second primary lung neoplasms.
One question that I have has to do with your not having listed bronchiolar carcinoma as a separate entity in your pathologic description. This is a neoplasm that is known to be multicentric, and I noticed that you have a 31% incidence of adenocarcinoma with no mention of bronchiolar carcinoma; what was the actual incidence of bronchiolar (bronchoalveolar) carcinoma in your series?
DR ANTAKLI: Thank you, Dr Benfield. We have excluded all cases of bronchoalveolar carcinoma just because of the question of multicentricity of those primary cancers. As to the question of what to do with a newly discovered lesion, we really do not spend too much time trying to figure out whether this is a second primary lesion or an actual recurrence. After careful restaging, which might involve use of different modalities including mediastinoscopy, we proceed with resection if we think that a resection would be curative. Eventually the question whether this is a second primary tumor or a recurrence is actually a question of prognosis. We know that the prognosis after a second primary tumor is better than the prognosis after resected recurrence, but actually the management plan is basically the same.
Related Article
Ann. Thorac. Surg. 1995 59: 863-867.
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