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J Thorac Cardiovasc Surg 2006;132:1388-1389
© 2006 The American Association for Thoracic Surgery
General Thoracic Surgery |
I have three questions. I was impressed by your cytopathologists and interventional radiologists who achieved a diagnosis by fine-needle aspiration on 58% of your patients with a subcentimeter nodule, but also I was disappointed that 45% of your patients underwent a PET scan for a 1 cm or less nodule that was nondiagnostic 41% of the time. What is your institution’s current algorithm for the workup of a subcentimeter pulmonary nodule?
Dr Lee. We do not generally obtain PET scans for subcentimeter nodules. Unfortunately, most of the patients we see in the office have already had a PET scan that was ordered by the referring physician.
In terms of workup for subcentimeter nodules, we are very privileged to have a very good interventional radiologist who can needle a lot of these subcentimeter tumors. That is probably not true in other institutions. Fifty-eight percent of our patients had tissue diagnosis obtained by fine-needle aspiration before resection. As part of our workup, we examine previous x-ray films or CT scans. If the nodule is a new growth, if it has suspicious CT findings of solid lesion and spiculation in someone who is older with a smoking history, then we proceed to fine-needle aspiration. If the nodule is not otherwise suspicious, we are inclined to monitor the patient by CT scan in 6 months or a year. I can tell you from our experience that we do not routinely order PET scans to work these nodules up, again, because of the data indicating high false negative results by PET scan in detecting subcentimeter tumors.
Dr Miller. My second question is in two parts and it concerns the histologic type of your tumors. Eighty-two percent of the tumors are either adenocarcinoma and/or bronchoalveolar carcinoma. In your study was there any difference in survival based on the histologic type? If so, was this difference related to nodal involvement because of the histologic type?
Dr Lee. We did not see any differences in survival among the different cell types. As you mentioned, 82% of the patients had adenocarcinomas, so the number of squamous cell cancers and large cell cancers is small in our study. The only survival difference that we noticed was among different stages, for example, stage IA versus non-IA.
Dr Miller. You had an outstanding 5-year and 10-year survival for your lung cancer deaths only for stage IA. How many of those patients had bronchoalveolar cancer? Such a high survival is very similar to the Japanese data.
Dr Lee. Nine patients had bronchoalveolar cancer in that group.
Dr Miller. And they were all in the IA group?
Dr Lee. Correct.
Dr Miller. Finally, 12% of your patients underwent a limited resection, either a wedge or segmentectomy. You found that there was no difference in survival based on the type of resection, and this is probably related to the small number in that subset. What are your institution’s current recommendations for the type of resection and the approach for these subcentimeter lung cancers, and especially in regard to bronchoalveolar cancer?
Dr Lee. Our institution has undergone a shift in terms of doing more and more thoracoscopic lobectomies over the past 3 or 4 years. The gold standard is still a lobectomy among good-risk patients. We need a large prospective randomized study looking at limited resection versus lobectomy to be able to fully answer that question. As it stands right now, if a patient is at good risk with a good performance status, we offer the patient a lobectomy. Now, if the patient has medical comorbidities or limited functional status, I think it is very reasonable to offer a limited resection. Although we had only 2 patients with N2 metastases, we did have 5 patients with intralobar satellites. The disadvantage of a limited resection is that you might miss the intralobar satellite lesions. Until we have the results of a large prospective randomized study, we do not have the full answer yet. As it stands right now, we do perform a lot of thoracoscopic lobectomies, and the only time we perform limited resection is for very small peripheral tumors and in someone who has poor performance status or limited pulmonary functions. There are also some studies suggesting that non-solid or bronchoalveolar cancer lesions might be more amenable to limited resection. We are looking at those questions and others with Dr Altorki.
Dr Darroch W. O. Moores (Albany, NY). Do you have any data on second primaries in this long follow-up, and if the patients had secondary primaries, did they have second operations?
Dr Lee. We did not look specifically at second primaries. We noted 5 recurrences overall in the patients with non-IA disease. There were also several patients in our series who had previous lobectomies for lung cancer. They were 6 or 7 years out from the first operation when their current second primary tumors developed.
Dr Jack A. Roth (Houston, Tex). Dr Lee, you mentioned that 21 of your patients were in the ELCAP study, so the lesion was picked up with screening, is that correct?
Dr Lee. Correct.
Dr Roth. Presumably the others were all incidental findings. What percent of those 21 patients actually had stage IA disease, and did you see any differences in survival in that group versus the patients who had the lesions picked up incidentally?
Dr Lee. Eighty-six percent of that group of 21 patients had stage I disease. There was only 1 patient in that group with N2 disease. We did not see any differences in survival between that screened group and the remaining group.
Dr Frank C. Detterbeck (New Haven, Conn). You corroborate what a number of other people have shown, that even for subcentimeter lesions there is a fairly high incidence of N1 nodal involvement or of other tumors in the lung, so that you should really do a lobectomy, even if it is a subcentimeter lesion. I think the PET scan data are also interesting. Again, they corroborate what others have shown, at least if we look at PET scans by the usual, conventional approaches, although there may be newer approaches to look at these scans that may be better. Your data in conjunction with a paper we just heard earlier about the low survival in the Surveillance Epidemiology and End Results database means that we should deplore what happens in the real world, where a small lesion is seen by a nonthoracic surgeon and the temptation to do a wedge resection is very strong and that is all that is done.
My question to you is this: there are actually fair amounts of data that nonsolid lesions have a low incidence of nodal involvement and a low incidence of any other invasion and can perhaps be appropriately treated by a wedge resection. Did you look at that in your dataset? How many of these were nonsolid lesions and what was the incidence of nodal involvement? Are those perhaps patients who can be treated by less than a lobectomy?
Dr Lee. That is a very good question. When we looked back at our current series at which patients had ground-glass opacity without any solid component, we did have 15 patients that radiographically had ground-glass opacity based on the report. We do not have the outcome data in terms of all patients presenting to us with ground-glass opacity measuring 1 cm or less. I think that is a very interesting point and something we can look into in the future. Keep in mind that our current study is a surgical series, and the way we did our initial search was to look at pathologic tumors 1 cm or less in size that have been resected.
Dr John Howington (Cincinnati, Ohio). With your outstanding survivals among these patients with 1 cm lesions and your previous experience with lung cancer screening, are you now routinely recommending screening among the families of these individuals with early-stage lung cancers who are smokers? Specifically, are you advocating to the community that they should undergo lung cancer screening?
Dr Lee. That is a very controversial topic. Clearly, among the 21 patients who were in screening, 76% of those patients were stage IA and were found to have high curability of these tumors. If your tumor is picked up in a subcentimeter level and is indeed in stage IA, you know from our data that you are essentially cured of the disease. However, I am not going to go into the downside of screening, as well as the cost involved. I am a firm believer in screening. I have a father who smokes and I pay out of my pocket to get him a CT scan every year.
Dr Altorki. I just have a comment. I would caution that we do not draw one conclusion one way or the other with respect to the efficacy of lesser resections in these subcentimeter tumors. Clearly, the impediment to doing a lesser resection here is mainly the presence of intralobar satellites, which occurred in roughly 5% of the patients in this particular series. One can make the argument that 95% of the patients could have been adequately treated by a lesser resection. What we really need is a random assignment trial that would answer that question. This study in no way supports doing it one way or the other. Dr Miller’s question is, what do we do? Well, what I do is that if I have somebody with a peripheral subcentimeter lesion, I offer the option of a segmentectomy.
Dr Joseph S. Friedberg (Philadelphia, Pa). Did those needle biopsies change your management, and did you have any that were false negatives that you subsequently followed and turned out to be positive? We would not normally do a needle biopsy if it looked like a suspicious lesion, which seemed to be your criterion. And just an observation: Do you have an explanation for the preponderance of women in your lung cancer population?
Dr Lee. All of the 48 tumors initially diagnosed by needle biopsy subsequently had pathology-proven confirmation after resection, so we did not have any false positive needle biopsies. In terms of false negative results, I do not have the answer to that in terms of this series. Again, our institution is a little skewed in that we do have a superb interventional radiologist who can needle these lesions and we have an on-site cytopathologist who looks at the adequacy of the specimen. I think without having him, probably more patients would have gone to the operating room for a diagnostic wedge resection. It does help in terms of planning the operation and discussion with the patient that we have a tissue diagnosis before the surgery. Some of these tumors are quite deep and it is hard to palpate thoracoscopically. If we have the needle diagnosis and we have a lot of confidence in the diagnosis, we go straight to a thoracoscopic lobectomy. We do not have to wedge out the lesion intraoperatively and wait to get a diagnosis by frozen section.
I do not have a good explanation for why we have more women in our series. I remember that there were also a substantial number of women in Dr Miller’s series of 100 patients with subcentimeter lesions.
Dr Friedberg. Were there any complications from all those needle biopsies?
Dr Lee. Generally the main complication is a pneumothorax, which occurred in 2% or 3% of patients, requiring a small pigtail catheter placed under fluoroscopy. I did not look at specifically which patients had a pneumothorax requiring a chest tube in this series. We have not had a patient requiring an operation as a complication of a needle biopsy.
Related Article
J. Thorac. Cardiovasc. Surg. 2006 132: 1382-1388.
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