Ann Thorac Surg 2007;83:202-203
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Eric Lim
Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, CB3 8RE United Kingdom
(Email: eric.lim{at}cvsnet.org).
The current international system for staging non-small cell lung cancer [1] is based solely on the anatomical distribution of disease and does not take into account the biological characteristics of the tumor. However, evidence is gathering for the contribution of tumor aggression as detected by histologic grade [2], molecular markers [3], and most recently genomic profile [4].
A relatively well-studied technique is the use of pleural lavage cytology, which fits in between as an anatomical marker of disease distribution linked to biological tumor aggression. Pleural lavage cytology is usually performed immediately after thoracotomy, by instilling a small amount of carrier solution, such as normal saline, and aspirating the results for cytologic detection of tumor cells. Although there have been differences in the timing of instillation, volume, and type of carrier solution, a consistent finding is the uniformly poor prognosis of patients with positive results.
A study by Satoh and colleagues [5] contributes to the work in this field by providing further information on the recurrence rates in patients with positive pleural lavage cytology results. A distinct strength of the study is the large sample size (853 patients), as the detection rate of patients with positive results can range from 4.5% to 40% [6, 7]. They reported a five-fold increase in pleural recurrence when positive cytology results were obtained; this is a pertinent finding given the background of a randomized trial that reported lower pleural recurrences when hypotonic cisplatin was instilled into the thorax of patients with positive pleural lavage cytology [8]. The impact of positive results on decreased survival was consistent, and the study underscores the impact of this technique on upstaging of early stage cell lung cancer.
The need to perform any adjunctive measure to increase the precision of staging can be expected to be met with lethargic uptake due to additional time, cost, and availability. Except pleural lavage cytology, unlike other more sophisticated adjuncts, is simple to perform, inexpensive, and available. It will be interesting to see if ACOSOG Z0040, a North American prospective study that also investigated the use of pleural lavage cytology, will produce new insights or have sufficient gravitas (should the results reflect current knowledge) to enthuse surgeons to undertake this adjunctive technique in which three characters "cy+" [9] at the end of a standard TNM staging report has the premonition of reduced survival and increased recurrence despite early-stage disease.
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Related Article
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Recurrence Patterns in Patients With Early Stage Non-Small Cell Lung Cancers Undergoing Positive Pleural Lavage Cytology
- Yukitoshi Satoh, Rira Hoshi, Yuichi Ishikawa, Takeshi Horai, Sakae Okumura, and Ken Nakagawa
Ann. Thorac. Surg. 2007 83: 197-202.
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