Ann Thorac Surg 2003;75:1751
© 2003 The Society of Thoracic Surgeons
Original article: general thoracic
Invited commentary
Douglas E. Wood, MDa
a Division of Thoracic Surgery, University of Washington, 1959 NE Pacific, AA-115, Seattle, WA 98195-6310, USA
e-mail: dewood{at}u.washington.edu
Doctor Osaki and colleagues have provided us with their large and well-analyzed experience of surgical resection for T4 nonsmall cell lung cancer. They have nicely identified the key point that we all try to communicate to our pulmonary medicine, medical and radiation oncology colleagues—that not all stage IIIB lung cancer is the same, and that selected patients may still benefit from surgical resection. It is certainly clear from the literature and from this paper that T4N0-1 disease is biologically different than the N3 disease that makes up the majority of stage IIIB lung cancer. However, too often these patients are not referred for surgical evaluation and tragically lose an opportunity for radical resection with curative intent.
Doctor Osaki and colleagues have given evidence to support the three important points considered by experienced thoracic surgical oncologists when confronted with a patient with T4 lung cancer. First, T4 pleural disease is not amenable to a complete surgical resection, has a grim prognosis, and is not appropriate for surgical resection. Second, the presence of N2 or N3 nodal disease is a strong surrogate for systemic disease, especially with T3/4 primary tumors. Since these patients do not benefit from surgery, preoperative mediastinoscopy is mandatory to identify occult mediastinal nodal disease and prevent a non-therapeutic thoracotomy. Finally, given the lack of benefit of an incomplete resection, preoperative determination of resectability and the ability to accomplish a complete resection are essential.
This final point becomes the most important and most controversial. The historical difference between T3 and T4 lung cancer is the determination of resectability. By textbook definitions, T4 lung cancer is considered "unresectable." Therefore, we should not be surprised that physicians treating lung cancer without close access to dedicated general thoracic surgeons may not even consider surgical consultation in these patients. However, even with surgical consultation, the determination of "resectability" in these patients is critical and is influenced greatly by the experience of the consulting thoracic surgeon. Surgeons with limited training, experience, or interest in the extended operations that these patients need may also declare the patient "inoperable" and refer them on for palliative chemotherapy and radiation. Although a variety of surgeons operate on patients for lung cancer, with equally varied morbidity, survival, and cost, it is in these patients with locally advanced disease where the inconsistency is most obvious and most disappointing. If we are to improve our results in lung cancer patients, the most important step is more consistent standardization of staging, determination of resectability, and logical application of adjuvant therapies. Following consensus-based treatment guidelines, such as those produced by the National Comprehensive Cancer Network (NCCN), is a good start, and an experienced thoracic surgical oncologist, able to resect selected T4 tumors, should be a key member of the lung cancer team.
