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J Thorac Cardiovasc Surg 2003;126:611
© 2003 The American Association for Thoracic Surgery

Letter to the editor

Malignant status at surgical margin of limited-resected non–small cell lung cancer: a crucial finding for predicting local relapse: Reply to the Editor

^a Department of Thoracic Surgery, Osaka Medical Center for Cancer & Cardiovascular Diseases, Osaka, Japan

We appreciate the questions raised by Sawabata in his letter about our article. In this article,¹ as well as the preliminary report,² we emphasized that this novel intraoperative lavage cytologic technique in limited surgery for lung cancer is clinically useful in checking for complete resection of the primary lesion. This technique is also widely applied in metastasectomy for metastatic pulmonary tumors.³

One of Sawabata’s questions is a problem of tumor cell contamination from the pleural surface when surgical margins of the resected specimens are washed. As described in our article,^1,2 when limited surgery is performed with a stapler alone, only all fired cartridges are washed, and therefore it is out of problem. When limited surgery is performed with the electric scissors or Nd:YAG laser, the specimen should be carefully washed without flooding of pleural surface. However, it is sometimes difficult to avoid flooding the pleura. When the pleural surface is carelessly washed, the result of intrathoracic pleural lavage cytologic examination immediately after thoracotomy should be taken into consideration⁴: Even if the surgical margin is cytologically positive, limited surgery is usually finished when pleural lavage cytologic examination is positive; when it is negative, the surgical mode should be carefully converted, considering together macroscopic and microscopic findings of surgical margin, especially in intentional cases.

Another question is a problem of the rate of positive cytologic results in the surgical margin after limited surgery for lung cancer. By Sawabata and colleagues’ "run-across" method⁵, the positive cytologic rate in the surgical margin was surprisingly high (47%), whereas it was lower (10%) by our method. We speculate that this result may be due to the difference of the clinicopathologic backgrounds of the tested patients. The data from Sawabata and colleagues’ method were obtained in only 15 compromised limited cases,⁵ whereas those from ours¹ were in not only 55 compromised but also 57 intentional limited cases. The number of Sawabata and colleagues’ tested patients was too small.⁵ Moreover, it may be reasonable that the rate in compromised cases was higher than that in intentional cases. In fact, the rate of positive cytologic results in compromised cases in our series was 18%.¹ Thus in compromised limited surgery the positive cytologic rate in the surgical margins may be strongly dependent on tumor size, tumor location, and, importantly, surgical cutting technique and indication for limited surgery. Therefore, because the positive cytologic rate in intentional limited surgery is rather more important, such data obtained by Sawabata and colleagues’ method⁵ should be shown. We think that the cause of the rate in our article¹ was not that the sensitivity of our cytologic technique was low. Comparative analysis is also needed between the "run-across" technique and our novel technique in checking accurately the surgical margins status of limited surgery for lung cancer.

	References

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1. Higashiyama M, Kodama K, Takami K, Higaki N, Nakayama T, Yokouchi H. Intraoperative lavage cytologic analysis of surgical margins in patients undergoing limited surgery for lung cancer. J Thorac Cardiovasc Surg. 2003;125:101–107[Abstract/Free Full Text]
   
2. Higashiyama M, Kodama K, Yokouchi H, Takami K, Nakayama T, Horai T. A novel test of the surgical margin in patients with lung cancer undergoing limited surgery: lavage cytologic technique. J Thorac Cardiovasc Surg. 2000;120:412–413[Free Full Text]
   
3. Higashiyama M, Kodama K, Takami K, Higaki N, Yokouchi H, Nakayama T, et al. Intraoperative lavage cytologic analysis of surgical margins as a predictor of local recurrence in pulmonary metastasectomy. Arch Surg. 2002;137:469–474[Abstract/Free Full Text]
   
4. Higashiyama M, Doi O, Kodama K, Yokouchi H, Tateishi R, Horai T, et al. Pleural lavage cytology immediately after thoracotomy and before closure of thoracic cavity for lung cancer without pleural effusion and dissemination: clinicopathological and prognostic analysis. Ann Surg Oncol. 1997;4:409–415[Medline]
   
5. Sawabata N, Matsumura A, Ohota M, Maeda H, Hirano H, Nakagawa K, et al. Cytologically malignant margins of wedge resected stage I non-small cell lung cancer. Ann Thorac Surg. 2002;74:1953–1957[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ken Kodama Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Higashiyama, M. Articles by Yokouchi, H. Search for Related Content PubMed Articles by Higashiyama, M. Articles by Yokouchi, H. Related Collections Lung - cancer Related Article