Ann Thorac Surg 2005;79:1714-1715
© 2005 The Society of Thoracic Surgeons
Original articles: General thoracic: Invited commentary
INVITED COMMENTARY
Peter Goldstraw, FRCS
Department of Thoracic Surgery, Royal Brompton Hospital, Sydney St, London, SW3 6NP United Kingdom
(E-mail: p.goldstraw{at}rbh.nthames.nhs.uk).
Tanaka and colleagues [1] report their experience in the diagnosis and treatment of 52 patients with a previous history of breast cancer found to have pulmonary nodules during a 10-year period. Clearly this is a highly selected subset of breast cancer patients referred to a thoracic department, in part because of the highly unusual pattern of the apparent relapse.
The authors reiterate the lessons learned in the pre-computed tomographic era of the early 1970s [2]. Such nodules may be metastatic from breast, new primary lung cancers, or a variety of benign conditions. These possibilities cannot be differentiated on the basis of the radiologic features, disease-free interval, or the multiplicity of nodules. Clearly tissue diagnosis is required to select appropriate therapy. However, we now have additional diagnostic procedures available that may obviate the need for thoracotomy. Fine needle aspiration biopsy, although not used in this series, is widely available and applicable to small lesions using computed tomographic guidance. Sophisticated immunohistochemistry can now assess receptor status, markers for specific sites of primary disease, such as thyroid transcription factor-1 and, in specialist centres, HER-2 neu expression on such tiny fragments. If this fails to provide adequate information for diagnosis and treatment and a target lesion of the appropriate size lies in a convenient location, excision biopsy using video assistance is feasible. There will remain a small subset of patients in whom thoracotomy remains the only diagnostic tool. The findings at surgery, supplemented by the limited information available on frozen section have usually determined the subsequent resectional strategy.
Tanaka and colleagues [1] go further and question the value of pulmonary metastasectomy in those patients found to have metastatic breast cancer. They suggest that the 5-year survival of 30.8% for this subset of their patients was no better than that which can now be achieved with modern chemotherapy and hormonal therapy. Although the results from the large International Registry of Lung Metastases [3] showed a significantly better 5-year survival for breast cancer patients with such a long disease-free interval; 45% if > 36 months, Tanaka and colleagues [1] clearly make an important point. Thoracic surgeons cannot be expected to be fully conversant with the treatment received by breast cancer patients, often over several years, nor be aware of the other options that are available once a diagnosis has been made and immunohistochemistry has been performed. If thoracotomy is necessary for diagnosis, the possible resectional strategies need to be discussed in a multidisciplinary setting ahead of surgery. Pulmonary metastasectomy, multiple, bilateral, even with anatomical resection may be appropriate, but only if this decision is based on a complete pathological analysis. Second phase thoracotomy may be preferable in other circumstances.
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References
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- Tanaka F, Li M, Hanaoka N, et al. Surgery for pulmonary nodules in breast cancer patients. Ann Thorac Surg 2005;79:1711–5..
- Cahan WG, Castro ElB. Significance of a solitary lung shadow in patients with breast cancer Ann Surg 1975;181:137-143.[Medline]
- Friedel G, Pastorino U, Ginsberg RJ, et al. Results of lung metastasectomy from breast cancer: prognostic criteria on the basis of 467 cases of the international registry of lung metastases Eur J Cardiothorac Surg 2002;22:335-344.[Abstract/Free Full Text]
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