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Ann Thorac Surg 2004;78:1753-1754
© 2004 The Society of Thoracic Surgeons

INVITED COMMENTARY

Department of Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA 98111, USA

gtsdel{at}vmmc.org

The report by Pechet and colleagues reviews the potentially important prognostic indicator of arterial invasion in patients with stage I non–small cell lung cancer. The study has retrospectively reviewed all patients with stage I cancer operated on within a three-year period. A subset of relatively homogeneous patients (n = 100) who had sufficient pathologic material for assessment and no previous surgical or pathologic issues which could affect prognosis were selected for in-depth review. The authors appropriately only included patients with anatomic resections, and 90% of the resections were carried out by a single surgeon. The remaining 10% of their study population had only mediastinal node sampling rather than mediastinoscopy and/or mediastinal node dissection resulting in a degree of inconsistency in postoperative staging.

Follow-up with respect to survival was complete and compelling. Five-year survival data were available in all patients. Before stratification on the basis of the presence of arterial invasion, five-year survival results are consistent with published expectations (IA, 62%; IB, 58%). However, patients with arterial invasion demonstrated marked differences in survival when analyzed according to stage (IA versus IB) and size (less than 2 cm versus greater than 2 cm). The difference was most pronounced in stage IA patients where five-year survival was 81% without arterial invasion, but dropped to 28% when arterial invasion was identified. Expressed differently, stage IA patients demonstrated median survival of 35 months with arterial invasion, whereas median survival in patients without arterial invasion was not reached at five years. Multivariate analysis demonstrated these differences were independent of patient demographics, tumor type, and grade.

Unfortunately, the information on cancer recurrence is available in only 64% of patients and for unexplained reasons the median follow-up is much less in patients with arterial invasion versus those without; 29 versus 69 months, respectively. This difference notwithstanding, 75% of patients with arterial invasion demonstrated tumor recurrence compared to 19% of those without arterial invasion. Unfortunately, information on differences in disease-free survival or more importantly patterns of recurrence are also not available.

This data is highly suggestive that arterial invasion should, and likely will, play a larger role in postoperative treatment decision making. The difficulty in short-term clinical application resides in the author's decision to require two slides and two areas of arterial invasion to subdivide their study populations. Requiring two slides is appropriate to ensure a baseline degree of pathologic assessment in each patient; however, most surgeons and oncologists when interpreting postresectional path reports will be informed whether arterial invasion was "present or absent." Whether one unequivocal area of arterial invasion should be considered less significant than two or more is currently not known. Equally important is the assumption that some unknown number of patients with a single focus of invasion were either excluded from study or alternatively included in the no arterial invasion study group.

The authors should be encouraged to complete their work by stratifying the degree of arterial invasion according to risk and pattern of recurrence and survival and, if two or more areas are discovered to be an important discriminator, then a change in the methodology of pathologic reporting should be encouraged.

The significance of vascular and lymphatic invasion is currently not well understood. Pechet and colleagues have produced highly suggestive data to support utilizing arterial invasion as a major prognostic indicator. Additional assessment is warranted in randomized populations to verify these findings and assess whether it is simply the presence or absence, or in fact, the degree of arterial invasion, which is important. These studies will be made potentially more applicable with the routine addition of positron emission tomography scans to improve preoperative staging accuracy. The authors also appropriately mention that arterial invasion ultimately may be a defining factor in which patients with early stage disease will benefit from adjuvant therapy.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Donald Low Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Low, D. Search for Related Content PubMed PubMed Citation Articles by Low, D. Related Collections Lung - cancer