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Ann Thorac Surg 1997;64:813
© 1997 The Society of Thoracic Surgeons
Division of Cardiothoracic Surgery, Department of Surgery, University of California Medical Center, 1150 Silverado St, Suite 110, La Jolla, CA 92037
Coming from Japan, this study of survival after resection of synchronous ipsilateral pulmonary metastasis is of special interest in view of the current revisions in the International System for Staging Lung Cancer [1]. The clinical classification of patients with satellite lesions in the same lobe or other tumor nodules in the ipsilateral lung is difficult due to the small number of patients identified for end results studies. Further, as noted by Yoshino and associates, a significant number of clinically apparent secondary nodules proved to be benign.
Some discussion of events that led to the current rules for classifying patients with this extent of disease may provide insight into the complexity of developing internationally acceptable rules for classification. An important study by Deslauriers and associates in 1989 [2] was the first published study of the influence of satellite nodules on prognosis. Deslauriers and associates showed that satellite nodules, which they considered a manifestation of local disease, had a deleterious effect on prognosis and they recommended that they be classified as T3, stage IIIA disease. Deslauriers and associates concluded that "this finding should not act as a deterrent to curative resection even if [the tumors are] located in a different lobe."
In this same time frame, my colleagues and I addressed this issue with similar findings and developed recommendations that were consistent with the existing definition for M1, that is, distant metastasis outside the hemithorax of origin and regional lymph nodes. These recommendations were also consistent with the general clinical practice: a patient whose disease was otherwise operable and resectable would still be considered for surgical resection. The American Joint Committee on Cancer and the Union Internationale Contre le Cancer adopted the following recommendations, which were published in the 1992 editions of their staging manuals. The rules for classification stated that "multiple tumor masses in the same lobe meeting the criteria for T1 should be designated as T2; a T2 tumor with another mass (not a lymph node) in the same lobe should be designated T3 and all other ipsilateral masses as T4."
In Japan, surgeons considered all satellite nodules to be M1 disease; thus these patients were placed in stage IV. In the present study, the stages were reclassified according to the 1992 rules and the data supported the validity of this classification. However, when the 1996 revisions in the staging system were under discussion at the Union Internationale Contre le Cancer-TNM Prognostic Factors Project Committee meeting in Geneva (May 1996), the Japanese representative submitted data supporting a classification rule that satellite tumor(s) within the primary-tumor lobe(s) of the lung should be classified T4 (stage IIIB) and intrapulmonary ipsilateral metastasis in a distant, that is nonprimary-tumor, lobe(s) of the lung should be classified M1 (stage IV) (I. Fleming, personal communication, 1996). This recommendation was adopted by the Union Internationale Contre le Cancer and the American Joint Committee on Cancer.
These various modifications are bound to be a source of confusion to many. We must keep an open mind and collect significantly more data to validate any classification rule. What we can say with some certainty is the following: (a) satellite lesions have an adverse effect on survival, (b) clinical classification by current technology is not highly reliable, and (c) regardless of classification, patients with satellite lesions should be considered for resection, if it is otherwise indicated.
References
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