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J Thorac Cardiovasc Surg 2000;119:193-194
© 2000 Mosby, Inc.

LETTERS TO THE EDITOR

Complete resection: Yes or no?

Division of Thoracic Surgery, National Cancer Center Hospital Japan, 1-1, Tsukiji 5-chome
Chuo-ku, Tokyo 104-0045, Japan

Reply to the Editor:

We appreciate the interest expressed by Kutlu, Sayar, and Metin in our consideration of the lobe-specific extent of systematic lymph node dissection for lung cancer. ¹ This has been a point of discussion among thoracic surgeons for a couple of decades.

Their question can be summarized as follows: Can a pulmonary resection be regarded as a "complete resection" if some mediastinal nodes are not examined? Indeed, we have shown that subcarinal dissection is not always necessary for tumors in the right upper lobe and the left upper segment because of very low prevalence of metastasis in subcarinal nodes for these tumors. However, is such a resection, even if the margin is completely free of tumor, really an "incomplete resection"?

I would like to address 2 issues regarding their question. First, the proper extent of lymph node dissection and the definition of complete (incomplete as well) resection in lung cancer should be discussed separately. The proper extent of lymph node dissection should be based on the prevalence of metastasis in each mediastinal site and the patient’s prognosis. Systematic lymph node dissection is intended for local control and subsequent improvement of survival, and it should be technically distinguished from simple lymph node sampling. In this sense, we consider that subcarinal dissection does not contribute to better local control when the superior mediastinum is free of disease (negative), and it is a rather time-consuming procedure in upper lobe tumors according to lobe-specific data. We think that the information gained from the superior mediastinal node can be a good surrogate for the subcarinal node.

Second, the definition of "complete (incomplete) resection" in lung cancer has not been uniform. Indeed, many investigators advocate that macroscopic or microscopic residual disease at the resection margin and the presence of tumor in the highest mediastinal node sampled at thoracotomy be considered as evidence of incomplete tumor resection. ^2-4 Others include perinodal extension as well. ⁴ Since the subcarinal node is not the highest station in the mediastinum (it is station 1 by Japanese definition and station 2 by United States definition), its positivity for tumor does not affect the judgment of "complete or incomplete resection." Here I agree that the definition of "complete (incomplete) resection" itself is problematic, as pointed out by Kutlu, Sayar, and Metin. The data from the Canadian Lung Oncology Group demonstrated a very limited prognostic significance of these definitions. ⁵ That seems reasonable considering the tumor’s nature of readiness to spread, such as in skip metastasis and occult distant metastasis in lung cancer. I believe that the definition of "complete resection" should be simply a resection without any evidence of residual macroscopic or microscopic tumor, regardless of nodal status.

I agree with Kutlu, Sayar, and Metin that the definition of complete resection in lung cancer requires revision. However, the strategy for systematic lymph node dissection should be better local control.

References

1. Asamura H, Nakayama H, Kondo H, Tsuchiya R, Naruke T. Lobe-specific extent of systematic lymph node dissection for non–small cell lung carcinomas according to a retrospective study of metastasis and prognosis. J Thorac Cardiovasc Surg 1999;117:1102-11.[Abstract/Free Full Text]
   
2. Lad T, Rubinstein L, Sadeghi A, for the Lung Cancer Study Group. The benefit of adjuvant treatment for resected locally advanced non-small-cell lung cancer. J Clin Oncol 1988;6:9-17.[Abstract]
   
3. Shields TW. The "incomplete resection." Ann Thorac Surg 1989;47:487-8.[Medline]
   
4. Mountain CF. Expanded possibilities for surgical treatment of lung cancer—survival in stage IIIa disease. Chest 1990;97:1045-51.[Abstract/Free Full Text]
   
5. Lacasse Y, Bucher HC, Wong E, et al. "Incomplete resection" in non–small cell lung cancer: need for a new definition. Ann Thorac Surg 1998;65:220-6.[Abstract/Free Full Text]
   

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Hisao Asamura Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Asamura, H. Search for Related Content PubMed PubMed Citation Articles by Asamura, H.