Ann Thorac Surg 1999;68:315
© 1999 The Society of Thoracic Surgeons
Invited Commentary
Walter B. Cannon, MDa
a General and Thoracic Surgery Palo Alto Medical Foundation Clinic 300 Homer Ave Palo Alto, CA 94301 USA
Invited commentary
The facts are clear. Patients presenting with non-small cell lung cancer who have extra-thoracic metastases will not benefit from resectional surgery. Being sure of the fact that the patient has extra-thoracic metastases is not so clear, however, but a good physical examination can exclude a high percentage of patients with extra-thoracic disease such as supraclavicular nodal involvement, axillary lymph nodal involvement, enlarged liver, bone pain, and possibly neurologic signs. These signs are usually quite clear and straightforward. The next level of subtlety of extra-thoracic, or at least extra-pulmonary evidence of metastatic disease, is best determined in 1999 by computed tomographic (CT) scanning. Although the CT scanner is not absolutely diagnostic of the stage of the disease, lymph nodes over 2 cm in diameter are almost always involved with metastatic tumor and the diagnosis can be readily proved most of the time by mediastinoscopy. Direct extension into the mediastinum and into the chest wall or to other structures within the chest cavity is not as clearly determined by CT scan but is strongly suggestive and relatively simple diagnostic procedures including thoracoscopy, can determine resectability. At the time of the chest CT it is very simple to do an extension of that CT scan to include the liver and the adrenal glands. This addition of regional scanning can be done with minimal inconvenience to the patient without a dramatic increase in cost and can be very helpful in determining extra-thoracic involvement. Once the mediastinum and the upper abdomen have been cleared, the potential of metastatic disease becomes quite low. However, as the authors have pointed out, bony metastases and central nervous system metastases may have no early signs or symptoms and thus many surgeons will proceed directly to a thoracotomy. The authors have made a valiant attempt to try to prove that even with patients who are asymptomatic, scanning of the brain can often pick up early metastases that would obviate the need for resectional therapy. They have correctly stated that the concept of "asymptomatic" varies with different institutions and with different physicians involved. However, they have shown that if a patient is truly symptomatic with increasing headaches, double-vision, weakness in an extremity, or personality changes of other subtle and not so subtle neurologic changes that a CT scan of the brain is absolutely necessary to rule out neurologic disease. The disturbing part of the CT scan is that although a patient may have neurologic metastases they may be so small that a standard CT or magnetic resonance imaging scanner will not be able to identify the lesion. However, because 50% of patients with any neurologic finding will have obvious metastatic disease on the CT scan, it is incumbent upon the surgeon to be sure to include that study in his workup prior to any consideration of resectional surgery. I believe that the only other issue that could be raised by this particular study is whether routine use of the CT scan is obviously obligatory in every patient with a small peripheral coin lesion on chest roentgenogram without evidence of mediastinal adenopathy. If there are no other contraindications to resectional surgery, one could consider proceeding directly to thoracotomy without the scan and the additional cost. It is a sobering thought, as the authors point out, how many patients actually have their presenting symptom of lung cancer as a neurologic event or other evidence of metastatic disease.
Related Article
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Surgeons’ assessment of symptoms suggesting extrathoracic metastases in patients with lung cancer
- Gordon H. Guyatt, Deborah J. Cook, Lauren E. Griffith, John D. Miller, Thomas R.J. Todd, Michael R. Johnston, Timothy L. Winton, Alan G. Casson, Richard I. Inculet, Gail E. Darling, Richard J. Finley, and Jean Deslauriers
Ann. Thorac. Surg. 1999 68: 309-315.
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