J Thorac Cardiovasc Surg 2003;126:609-610
© 2003 The American Association for Thoracic Surgery
Negative aspects of preoperative delay in early stage non–small cell lung cancer
A. Sortini, PhDa,
D. Sortini, MDa,
G. Carrella, MDa
a Department of Surgical, Anaesthesiological, and Radiological Sciences, Section of Clinica Chirurgica, University of Ferrara, Ferrara, Italy
To the Editor:
We would like to express or opinion about the article of Quarterman and associates,1 "Effect of Preoperative Delay on Prognosis for Patients With Early Stage Non–Small Cell Lung Cancer." We think that in this work there are some negative aspects. The first is based on the assumption that larger tumors are larger because they are more aggressive. So if you diagnose a solitary pulmonary nodule of 2 cm diameter and if the contention that "larger tumors might present as larger tumors because they are more aggressive and not simply because they are older"1 is biologically true, is the nodule that you have diagnosed an older less aggressive nodule or an aggressive nodule in early phase? If the nodule diagnosed is an aggressive nodule in the early phase, is it acceptable to take a "watch and wait" approach, or, without any histologic findings from less invasive methods, is prompt surgery a better option? Until it can be ascertained that a nodule is nonaggressive without a histologic diagnosis, we prefer the surgical approach.
The second negative aspect in the work of Quarterman and associates1 is the cutoff between diagnosis and delayed resection. We think that no surgeon should wait so long for perform a surgical operation in a patient with the diagnosis of solitary pulmonary nodule. In fact, isn’t the correct cutoff 90 days, because the maximum delay between diagnosis and treatment is 10 or 15 days? We therefore consider it wrong to compare patients operated on within 90 days and at least 90 days after presentation. It would be more correct to compare patients operated on within 15 days and patients operated on at least 90 days after diagnosis. We think that the watch and wait approach is not the best choice. We prefer the surgical approach, because the survival after surgical resection improves dramatically for stage 1A; in fact, for primary lesions smaller than 3 cm with no nodal spread, the 5-year survival approaches 70% to 80%.2 For us the surgical approach for solitary pulmonary nodules is the criterion standard even for patients with a history of malignancy,3 for whom an immediate histologic diagnosis is still more important. We do apply the watch and wait approach, but only for well-selected patients (young, without history of malignancy or smoking, with a nodule radiologic pattern of benignity or nodules with small dimension). We think that the clinician in a well-determined situation does have the option of a short watchful period.4 But for us the watchful period doesn’t last 90 days without any radiologic control; in fact our waiting period is shorter than 90 days, and every 20 days we perform a thoracic computed tomographic scan.
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References
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- Quarterman RL, McMillan A, Ratcliffe MB, Block MI. Effect of preoperative delay on prognosis for patients with early stage non–small cell lung cancer. J Thorac Cardiovasc Surg. 2003;125:108–114[Abstract/Free Full Text]
- Tang AW, Moss HA, Robertson RJ. The solitary pulmonary nodule. Eur J Radiol. 2003;45:69–77[Medline]
- Andrea S, Paolo C, Ascanelli S, Davide S, Enzo P. Significance of a single pulmonary nodule in patients with previous history of malignancy. Eur J Cardiothorac Surg. 2001;20:1101–1105[Abstract/Free Full Text]
- Ginsberg RJ. The solitary pulmonary nodule: can we afford to watch and wait? J Thorac Cardiovasc Surg. 2003;125:25–26[Free Full Text]
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