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J Thorac Cardiovasc Surg 2007;134:822-823
© 2007 The American Association for Thoracic Surgery
Letter to the Editor |
a Department of Thoracic Surgery and Radiology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
b Department of Assistive Diagnostic Technology, National Cancer Center Hospital, Tokyo, Japan
We appreciate the comments by Sawabata. Sawabata and colleagues previously reported that a cytologic examination at the staple margin of wedge resection for lung cancer predicted a recurrence at the margin better than a histologic examination.1
In this article, Sawabata and coworkers described that 7 of the 15 patients (47%) who underwent wedge resection showed positive cytology at the staple margin, whereas histologic examination showed positive cytology in 3 of the patients (20%). Four of the 7 patients with a positive cytology margin had margin relapse. However, 3 of the 4 patients with recurrence showed a negative histology margin at the staple. In a multicenter prospective study, Sawabata and colleagues2 also reported that 40 of 118 patients (34%) showed a positive cytology margin on the staple line in wedge resection for lung cancer, whereas histology showed a positive margin in 18 of the 118 patients (15%). Therefore, they concluded that the cytologic diagnosis on the staple line was more sensitive than histologic diagnosis to show remaining cancer cells at the surgical margin of wedge resection.
Although we have never experienced such a high rate of margin relapse (27%), as well as positive histology margin (20%), in patients with lung cancer who underwent wedge resection, cytologic examination on the staple line could be useful for examining a margin of segmentectomy. Before our present study, one of the authors (H. N.) experienced a margin relapse in a patient who was undergoing upper division segmentectomy for adenocarcinoma, which was treated by completion upper lobectomy afterward. In that patient, although the histology margin was negative in the specimen, cancer cells might remain on the staple margin of segmentectomy. Although histology can show a limited area of the margin, cytologic examination may be able to determine the overall length of the staple line.
However, histologic diagnosis is usually more reliable than cytologic diagnosis. In addition, cytologic examination sometimes shows a vague diagnosis, such as, "it is suspected of malignancy." In fact, Sawabata and colleagues’ results1 showed a cytology positive margin in 47%, which could include false-positive results. Higashiyama and coworkers3 reported far less frequency; a cytologic examination of the surgical margins in patients undergoing limited surgery for lung cancer showed positive results in 11 of 112 patients (9.8%). Although we do not usually use cytologic examination on the staple line in both segmentectomy and wedge resection, we have judged the complete resection by macroscopic findings and histologic diagnosis on the surgical margin. If cytologic examination on the staple line showed positive results, we would determine a further resection by both macroscopic findings and histologic diagnosis of the surgical margin. If we judge the margin to be positive from the total findings, we will further resect the next segment or convert to lobectomy. In fact, we did perform a segmentectomy for 2 segments or 1 segment with 2 subsegments in some patients to take a sufficient surgical margin in our study.
In a multicenter study, Sawabata and colleagues4 also reported that the surgical margin was usually negative when the margin distance was greater than 2 cm or the maximum tumor diameter. In our segmentectomy, the margin is usually more than 2 cm as described in the article,5 which could be sufficient to make a negative margin. In addition, to make a surgical margin sufficient in segmentectomy, we usually cut the lung surface by electrocautery before cutting by the stapler on the segmental plane, which can make the margin greater than using a stapler alone on lung tissue. Sawabata and colleagues4 also reported on a device to make a surgical margin sufficient, that is, a less traumatic jaw closing-type stapler can make the surgical margin negative more frequently than an aggressive clumping type.
We agree with Sawabata and colleagues that an intraoperative histologic or cytologic examination on the surgical margin is important, as well as N-staging during segmentectomy, and that a device to make the margin sufficient is also important.
References
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