J Thorac Cardiovasc Surg 2005;130:1479-1480
© 2005 The American Association for Thoracic Surgery
Malignant margin in wedge resection for peripheral lung cancer and adjuvant radiotherapy
Noriyoshi Sawabata, MD,
Masayoshi Inoue, MD,
Hiroyuki Shiono, MD,
Masahito Monami, MD,
Meinoshin Okumura, MD
Division of General Thoracic Surgery, Department of Surgery (E-1), Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 560-8552, Japan
To the Editor:
We read with interest the article by Shennib and associates
1
regarding wedge resection and local radiotherapy for peripheral lung cancer in high-risk patients. They stated that pathologically staged T1 lesions can be successfully resected in 75% of cases; however, narrow resection margins remain a concern. Knowing the efficacy of local radiotherapy, the type of failure, whether there is local-regional recurrence, and the malignant status of surgical margins is crucial.
To obtain an accurate diagnosis of malignant status at the surgical margins is sometimes difficult because stapled resection is most frequently used. Staples have to be removed to examine the margins pathologically. Therefore pathologic diagnosis with frozen sections is not an option, although a method of cytology can be used to diagnose the malignant status of surgical margins. We found that a cytologic method to diagnose the malignant status of surgical margins can predict the risk of recurrences at the surgical margins.
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In addition, we found that an optimal distance from the tumor to the surgical margin was more than the maximum tumor diameter to obtain a safe margin. In the resent issue the authors defined a sufficient margin distance to be more than 1 cm. When a tiny peripheral lesion less than 1 cm in diameter is removed, margin distance of less than 1 cm could be sufficient. Margin distance and margin cytology could be criteria of adjuvant radiotherapy.
It is generally accepted that limited lung resection is safe and effective in a selected group of patients. However, there is a great concern about local-regional recurrences. The percentage of local-regional recurrences is reported to be 39% in a study containing more than 100 cases conducted by Landreneau and coworkers.
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Radiation therapy has been indicated, either brachytherapy
4,5
or local radiotherapy,
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to prevent such failures. As such, type of failure is a matter of concern. As shown in Table 1, Lee and colleagues
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and Fernando and associates
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reported that the local-regional recurrence ratio was reduced to 2% to 6% in a group of patients who underwent wedge resection and brachytherapy. Unfortunately, the frequency of recurrences is not stated in the recent report.
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In addition, an adverse effect of pneumonitis was observed in 14% in cases of local radiotherapy. Considering this, brachytherapy might be a more acceptable method than local radiotherapy if the local-regional recurrence ratio was more than or equal to that of brachytherapy.
Adjuvant radiotherapy in cases of limited resection of lung cancer might be a hopeful treatment in selected patients. Accurate diagnosis of the malignant status of surgical margins and efficacy to prevent surgical margin recurrence are matters of concern. We hope to see the mature follow-up results of CALGB 9335.
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References
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- Shennib H, Bogart J, Herndon JE, et al. Cancer and Leukemia Group BEastern Cooperative Oncology Group Video-assisted wedge resection and local radiotherapy for peripheral lung cancer in high-risk patients. the Cancer and Leukemia Group B (CALGB) 9335, a phase II, multi-institutional cooperative group study. J Thorac Cardiovasc Surg 2005;129:813-818.[Abstract/Free Full Text]
- Sawabata N, Ohta M, Matsumura A, et al. Optimal distance of malignant negative margin in excision of nonsmall cell lung cancer. a multicenter prospective study. Ann Thorac Surg 2004;77:415-420.[Abstract/Free Full Text]
- Landreneau RJ, Sugarbaker DJ, Mack MJ, et al. Wedge resection versus lobectomy for stage I (T1 N0 M0) non-small-cell lung cancer. J Thorac Cardiovasc Surg 1997;113:691-698.[Abstract/Free Full Text]
- Lee W, Daly BD, DiPetrillo TA, et al. Limited resection for non-small cell lung cancer. observed local control with implantation of I-125 brachytherapy seeds. Ann Thorac Surg 2003;75:237-242.[Abstract/Free Full Text]
- Fernando HC, Santos RS, Benfield JR, et al. Lobar and sublobar resection with and without brachytherapy for small stage IA non-small cell lung cancer. J Thorac Cardiovasc Surg 2005;129:261-267.[Abstract/Free Full Text]
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Reply to the Editor
- Hani Shennib
J. Thorac. Cardiovasc. Surg. 2005 130: 1480.
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