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J Thorac Cardiovasc Surg 2008;135:267-268
© 2008 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Thomas A. D'Amico (Durham, NC). I congratulate both authors for this thoughtful study that describes the incidence of nodules that may have been missed at resection for lung cancer, a concept derived from experience with thoracoscopic metastasectomy.

Just as with metastasectomy, it is possible that thoracoscopic exploration for resection of lung cancer will miss nodules, some of which may be malignant. However, in this study, as in others, the majority of missed nodules are benign. Regarding the malignant nodules, the presence has been demonstrated, but the significance, as you said, has not. I and others, I'm sure, are surprised that so many of the nodules missed were 6 mm or larger, including all 3 of the noncarcinoid second primary lesions. One would expect a 64-slice scanner to perform better.

Future studies are required to elucidate the significance of these missed nodules in patients with both benign and secondary pulmonary malignancy. It is possible that sequential thoracoscopic procedures have a better outcome than thoracotomy in some patients, depending on the biology of the tumor.

In light of your study and these comments, I have four questions. What percentage of your patients underwent mediastinoscopy? You found many more patients with N2 disease than with second primary lesions.

Second, why did you not include thoracoscopic exploration as part of your study to determine the true incidence of the missed nodules? Thoracoscopic exploration may have found pleural or other disease that would preclude thoracotomy.

Third, in this study, 14 of 166 patients had missed malignant nodules. Of these 14, 9 of 14, or 5%, were thought to have M1 lesions. Five of those 9 already met criteria for adjuvant chemotherapy. Thus only 4 patients, or 2%, . . . [Full Text of this Article]