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J Thorac Cardiovasc Surg 2007;134:822
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

A segmentectomy for stage IA non–small cell lung cancer should be associated with surgical margin cytology findings and a frozen section histologic examination of lymph nodes

Department of Cardiothoracic Surgery, Dokkyo Medical University School of Medicine, Shimotsuga, Japan

To the Editor:

I enjoyed reading the article written by Nomori and colleagues.¹ Their strategy for performing a segmentectomy with little risk of local relapse included the following features: (1) Hilar and mediastinal lymph nodes are dissected as much as possible, (2) the lobectomy must be completed when metastasized cancer is found in any of the dissected lymph nodes, and (3) in nested cases with a sentinel node, frozen section histologic examinations can be limited to the sentinel lymph node.

I agree with their strategy regarding local/regional recurrence in the lymphatics. However, the crucial concept of possible local relapse is not addressed, because a relapse of non–small cell lung cancer can occur at the surgical margin, which is independent of the lymphatic system.

When complete excision has been accomplished with compromised patients with clinical stage I non–small cell lung cancer, surgical margin recurrence has been observed in approximately half of the cases with malignant cytologic results, even when the margin showed a malignant negative histology.^2,3 Thus, a cytologic malignant positive margin in the residual lung after a segmentectomy has the potential of surgical margin relapse. On the basis of my experience with complete excisions for compromised patients, the segmentectomy should be accompanied by a surgical margin cytologic examination and frozen section histology findings of the dissected hilar and mediastinal lymph node.

I have performed 22 segmentectomies without lymph node metastasis, in which there were 2 cases (9%) with malignant positive cytology results at the surgical margin, for which completion lobectomies were performed. If those residual lobes had been left, surgical margin relapse may have occurred, even though there was no metastasized lymph node. Thus, I recommend performing a surgical margin cytologic examination in patients who undergo a segmentectomy and in cases of excision, because malignant cytology findings have been documented in cases with malignant negative histology findings.^4,5

Here are some questions for Dr Nomori and colleagues: What was the status of the margin of the lung that underwent a segmentectomy? Was a margin cytologic examination carried out? Also, what options do you propose if the margin cytology were shown to be malignant positive by a cytologic method?

References

1. Nomiri H, Ikeda K, Mori T, Kobayashi H, Iwatani K, Kawanana K, et al. Sentinal node navigation segmentectomy for clinical stage IA non-small cell lung cancer. J Thorac Cardiovasc Surg 2007;133:780-785.[Abstract/Free Full Text]
   
2. Sawabata N, Matsumura A, Ohota M, Maeda H, Hirano H, Nakagawa K, et al. Thoracic Surgery Study Group of Osaka University Cytologically malignant margins of wedge resected stage I non-small cell lung cancer. Ann Thorac Surg 2002;74:1953-1957.[Abstract/Free Full Text]
   
3. Sawabata N, Takeda SI, Inoue M, Tokunaga T, Koma M, Maeda H. Spread of malignant cells in the surgical margin with stapled excision of lung cancer: comparison of aggressive clump and less traumatic jaw closure type staplers. Thorac Cardiovasc Surg 2006;54:418-424.[Medline]
   
4. Sawabata N, Ohta M, Matsumura A, Nakagawa K, Hirano H, Maeda H, et al. Thoracic Surgery Study Group of Osaka University 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]
   
5. Sawabata N, Mori T, Iuchi K, Maeda H, Ohta M, Kuwahara O. Cytologic examination of surgical margin of excised malignant pulmonary tumor: methods and early results. J Thorac Cardiovasc Surg 1999;117:618-619.[Free Full Text]
   

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This Article Full Text (PDF) 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 Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Noriyoshi Sawabata Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sawabata, N. Search for Related Content PubMed Articles by Sawabata, N. Related Collections Related Article