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Ann Thorac Surg 2004;78:1909
© 2004 The Society of Thoracic Surgeons
Department of Surgery, Texas A&M University Health ScienceCenter College of Medicine, Scott and White Memorial Hospital, 2401 S 31st St, Temple, TX 76508
The article by Cerfolio and colleagues is an important addition to the literature in regard to our continuing struggle with how to best incorporate multidisciplinary care in the management of lung cancer patients. The fact that this is necessary is no longer debatable in this author's opinion. More than 70% of patients have systemic disease at the time of diagnosis, and we have hopefully and finally come to grips with the fact that a recurrence rate of 20% to 40% for "surgically curable" patients is not satisfactory. It has been known for quite some time by our medical oncology colleagues that radiographic findings do not necessarily correlate with chemotherapy effects on a solid tumor, and some of these clinicians, such as those that treat gastrointestinal stromal and germ cell tumors, have already been using positron emission tomography (PET) and computed tomography (CT) as a measure of true response. However, how to apply this to the treatment of lung cancer is a bit more problematic. After years of equivocal "statistical near miss" reports and a great deal of debate, recent more definitive studies from Europe have suggested that adjuvant chemotherapy is probably as important in lung cancer patients, regardless of stage, as it has been for those with breast cancer. Although at many centers the use of neoadjuvant treatment for stage IIIA has been common, it has not been routine practice around the world, and with this new information many centers have now abandoned its use for adjuvant protocols. The Intergroup S9900 trial utilizing neoadjuvant chemotherapy for early stage lung cancer patients has been closed due in large part to this shift of thinking and associated lack of recent accrual, and the final data analysis is pending. Where does this leave the use of PET and CT in the evaluation of response to treatment for lung cancer being considered as candidates for surgical resection? It is likely that some centers will continue to use neoadjuvant treatment for stage IIIA patients, and many will continue its use in T4 tumors that are considered to be "borderline" resectable. Certainly it could be recommended that we continue to utilize PET and CT scanning in these patients to aid in the decision making process for whom to resect after these treatments.
As we continue to develop more effective biologically based systemic agents as well as more sensitive imaging techniques, the use of PET and CT and related modalities may well be expanded. In these scenarios, the decision to operate on localized disease may hinge less on the continued presence of a radiographic density than on an abnormality that demonstrates metabolic activity, or "signs of life." Patients with metastatic disease may also be impacted, as these types of imaging are used to determine more accurate response at distant sites. We may begin to expand surgical treatment for those that have eradication of metastatic foci, and offer subsequent "local control" or "salvage" surgical therapy for the primary lesion. In either case, metabolic imaging is likely to be an increasingly useful adjunct to our decision making process for surgical treatment of thoracic malignancies.
Related Article
Ann. Thorac. Surg. 2004 78: 1903-1909.
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  W A Weber PET for response assessment in oncology: radiotherapy and chemotherapy Br. J. Radiol., November 1, 2005; Supplement_28(1): 42 - 49. [Abstract] [Full Text] [PDF]
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