Ann Thorac Surg 2002;73:1075
© 2002 The Society of Thoracic Surgeons
Invited commentary
Richard F. Heitmiller, MDa
a Chief of Surgery, Union Memorial Hospital, 3333 North Calvert St, Suite 610, Baltimore, MD 21218-2898, USA email: richardhe@helix.org
The paper by Watanabe and colleagues reflects an interesting and important trend in the surgical management of patients with non-small cell lung cancer (NSCLC). The evolution of the surgical management of patients with NSCLC is well known. Pneumonectomy, introduced in 1933, was displaced by lobectomy approximately a decade later. Lobectomy, it was shown, yielded cancer survival results equal to pneumonectomy with considerably less morbidity and mortality. Since that time, lobectomy has withstood challenges from open and video-assisted thoracic surgery (VATS) segmental and wedge resections, and remains the "standard" lung resection for patients with NSCLC, as it continues to yield the best combination of survival and local control rates of any resection technique.
The treatment algorithm in the study by Watanabe and colleagues, which advocates VATS wedge resection for patients with focal bronchioalveolar lung cancer, would at first seem to defy thoracic surgical historical experience. Rather than ignoring the lessons of the past, however, this treatment protocol is a result of two important developments in the present. The first of these is a developing understanding of the pathogenesis of peripheral glandular lung cancers. Rather than developing de novo, it is now believed that adenocarcinoma, like central bronchogenic tumors, develop through a well-defined sequence: metaplasia-dysplasia-carcinoma in situ-invasive carcinoma. Acceptance of this new pathogenesis model has important therapeutic implications. If lung adenocarcinoma arises through a well-defined sequence, and if this progression can be identified and interrupted, then invasive adenocarcinoma could be prevented or resected at its earliest stage. This is exactly what the current study is advocating. Early surgical resection for preinvasive lung adenocarcinoma would, therefore, be analogous to prophylactic esophagectomy for high grade dysplasia in patients with Barrett mucosa.
The second new development is in computed tomographic (CT) imaging. Spiral CT scanning has now achieved such high resolution that not only can small lung cancers be detected, but also early, pre-invasive peripheral glandular lung pathology. The accurate correlation between CT and pathologic findings, for in situ bronchioalveolar adenocarcinoma, is clearly cited in this study by Watanabe and colleagues.
For the last 70 years, thoracic surgeons have worked to determine the optimal therapy to treat lung cancers which are already well-established by the time of initial presentation. We have compared and refined resection techniques, and developed combination therapy protocols to treat patients with locally advanced-stage disease. However, this study suggests that the next major development in NSCLC treatment will come from advances in our understanding of lung tumor pathogenesis, and our increasing ability to identify patients at an early or preinvasive stage of disease.
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Results of wedge resection for focal bronchioloalveolar carcinoma showing pure ground-glass attenuation on computed tomography
- Shun-ichi Watanabe, Toshio Watanabe, Kazunori Arai, Takahiko Kasai, Joji Haratake, and Hiroshi Urayama
Ann. Thorac. Surg. 2002 73: 1071-1075.
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