Ann Thorac Surg 2004;77:1161-1162
© 2004 The Society of Thoracic Surgeons
Invited commentary
Harvey Pass, MD
Division of Cardiothoracic Surgery Karmanos Cancer Institute/Wayne State Suite 2102 Harper Prof Bldg 3990 John R Detroit, MI 48201, USA
e-mail: hpass{at}dmc.org
The manuscript by Sakao and colleagues further emphasizes the need for thoracic surgeons to catch up with technology and biology in the management of lung cancer, and elegantly combines both of these elements. We all keep on trying to define a novel marker of prognostication or early detection with incredibly expensive technologies including gene expression arrays and proteomic expression profiles; however, maybe it is time (in the interim while a multitude of laboratories try to validate new markers) to step back like these authors have and use intuition to evaluate what we have! The paper combines new age computerized tomographic interpretations to distinguish morphologic differences in the small pulmonary nodule, and is able to correlate these findings with the Noguchi classification of nodules. This is important because it further reinforces that thoracic surgeons must distinguish between solid and nonsolid components (ground glass opacity) because they have prognostic import. Moreover, these authors have combined with the radiologic interpretation a biologic component, ie, the carcinoembryonic antigen level, which when elevated along with a nonreplacing type of nodule on computed tomography, drastically alters the prognosis of these supposedly "good risk" patients. The multivariate analysis data are convincing, albeit small, and demand prospective validation.
The greater implication here, besides recognizing the heterogeneity of Stage I lung cancer based on size, is that a redefinition of our present staging system is in order. Once again, size matters in Stage I lung cancer, but our size ranges may need to be modified. The impact of the radiologic findings also make one wonder whether if we are getting to a point where computerized definition of nodules combined with a sensitive and specific marker, along with metabolic imaging will influence our need for histologic confirmation of the small pulmonary nodule with a bad prognosis. With lung cancer screening research programs in high gear internationally trying to define precise computed tomography interpretation along with relevant biologic markers, our strategies for diagnosis and therapy after the discovery of small solid nodules could be altered. Certainly, if a patient presents with a small nodule with bad risk demographics, which portend early death or recurrence, surgeons will clamor for novel therapies including induction approaches. What really stretches the envelope is whether we will be satisfied to clamor for this without a histologic diagnosis of the nodule and rely on the noninvasive, ie, computed tomography and marker combination. This paper is a prelude to that...expect more like it in the future.
