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The Achilles’ Heel of Lung Cancer Resection in the United States

The Achilles’ Heel of Lung Cancer Resection in the United States

EDITORIAL The Achilles’ Heel of Lung Cancer Resection in the United States Ramón Rami-Porta, MD W hen Cahan and his colleagues1,2 at the Memorial S...

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The Achilles’ Heel of Lung Cancer Resection in the United States Ramón Rami-Porta, MD


hen Cahan and his colleagues1,2 at the Memorial Sloan-Kettering Cancer Center of New York first systematized pneumonectomy, and later lobectomy, for lung cancer, they associated an intraoperative mediastinal lymph node assessment depending on the lobar location of the primary tumor as an ineludible maneuver in the surgical treatment of the disease. In Japan, the National Cancer Center of Tokyo was opened in 1962 to fight all types of cancer based on three fundamental principles: sound administration; comprehensive and multidisciplinary clinical care; and solid research. One of their projects for surgical treatment of cancers was the “evaluation of prognosis achieved by various kinds of surgical procedures combined with lymph node removal and adjuvant chemotherapy.”3 This principle was duly put into practice by the Japanese thoracic surgeons of that time and their followers.4,5 Since then, some intraoperative evaluation of the regional lymph nodes has been considered essential by individuals, working groups, and scientific societies to achieve a complete resection of lung cancer.6–9 However, although this practice has been followed strictly in Japan, where a lung resection without some sort of intraoperative mediastinal nodal assessment would be inconceivable, it has not permeated the thoracic surgical community in the United States beyond the institutions of excellence that give credit to North American medicine. The article by Osarogiagbon and Yu,10 included in this issue, reports revealing results from the analysis of the Surveillance, Epidemiology and End Results database: 62% of patients with pathologic (p) N0 or pN1 non–small-cell lung cancer had no mediastinal lymph nodes examined at operation. This was after the exclusion of patients for whom mediastinal nodal examination could have been avoided, such as those undergoing exploratory thoracotomies. This is an astonishing fact: 7711 patients of 12,349 who underwent resection for lung cancer and were registered in the Surveillance, Epidemiology and End Results database between 1998 and 2002, had no mediastinal lymph nodes examined. In this population the absence of mediastinal nodal exploration was associated with a significantly lower overall (52% versus 47%) and cancer-specific (63% and 58%) 5-year survival rates. Undoubtedly, this is, at least in part, because of the fact that some of the patients, whose tumors were classified as pN0 or pN1, had involved mediastinal lymph nodes that had passed unnoticed. Lack of exploration of these nodes prevents proper pathologic staging and the administration of adjuvant chemotherapy, which has proved to have an impact on prognosis.11 It would be presumptuous to pretend to identify the causes of this surgical failure from the other side of the Atlantic, but one can certainly speculate as Osarogiagbon and Yu10 have done: specialty training, surgical volume, hospital volume, teaching status, pathology practice. All this, however, can be traced back to education and training. If a thoracic surgeon is properly trained, or for that matter, if a general surgeon is properly trained in thoracic surgery and in the principles of oncologic surgery, the case volume, the type of practice, or the teaching status of the hospital should not be limiting factors

Thoracic Surgery Service, Hospital Universitari Mútua Terrassa, Barcelona, Spain. Disclosure: The author declares no conflict of interest. Address for correspondence: Ramon Rami-Porta, MD, Thoracic Surgery Service, Hospital Universitari Mútua Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona Spain. E-mail: [email protected] Copyright © 2012 by the International Association for the Study of Lung Cancer ISSN: 1556-0864/12/0712-1742


Journal of Thoracic Oncology  •  Volume 7, Number 12, December 2012

Journal of Thoracic Oncology  •  Volume 7, Number 12, December 2012  TheAchilles’HeelofLungCancerResectionintheUnitedStates

in performing some type of intraoperative assessment of the mediastinal lymph nodes. If the removed mediastinal lymph nodes are separated from the lung specimen, and properly labeled by the surgeon, the pathologists will find no difficulty in examining them and have no excuse to not examine them. In such big countries and heterogeneous continents as the United States and Europe, differences in teaching programs and limited exposure to thoracic oncology issues during residency training may be the cause of suboptimal practice. In this case, the role of scientific societies is fundamental. In Spain, for example, the Spanish Society of Pneumology and Thoracic Surgery issued a consensus document with clear definitions and indications of the different types of intraoperative mediastinal exploration.12 In Europe, the European Society of Thoracic Surgeons, aware of the differences in health care systems, training and practice across the continent, published guidelines on types and indications of intraoperative mediastinal nodal assessment, to set the standard of the minimum required for routine clinical practice.9 The result is that there is a collective awareness that some sort of intraoperative mediastinal exploration is mandatory in most surgical candidates. Among the 24090 lung resections for lung cancer submitted to the European Society of Thoracic Surgeons Thoracic Database by 220 thoracic surgery units, from 2007 to 2012, 80% had systematic nodal dissection, 11% had other type of nodal assessment, and only 9% had either no sampling or the procedure was unknown.13 Intraoperative nodal assessment is important not only for identifying N2 disease and making postoperative therapeutic decisions, but also for proper definition of the absence of nodal involvement—the pN0 status.14 In 1997, the International Association for the Study of Lung Cancer defined systematic nodal dissection in an international and multidisciplinary consensus meeting;15 and in 2005, it defined node-specific systematic nodal dissection.8 In either type of dissection, three mediastinal nodes and three hilar/ intrapulmonary nodes had to be retrieved for proper intraoperative nodal staging and definition of the pN0 status. Those who practice systematic nodal dissection routinely know that six nodes are a small number compared with the nodes that can be found in the mediastinum, but this standard was set to stimulate nodal exploration in lung cancer resection, and it is better than retrieving no mediastinal nodes at all. Osarogiagbon and colleagues16,17 have a sharp eye in identifying failures in surgical and pathological practice, but they propose effective solutions too.18 It is this process of focused research on a specific problem, constructive criticism, and proposal of solutions that makes improvement possible. Osarogiagbon and colleagues are dealing with a crucial problem that affects the United States, and surely other

countries, and are starting to solve it in their own institutions and ­working groups. It would be desirable if professionals in other countries also followed their example and increase the rate of intraoperative mediastinal nodal exploration in every lung cancer resection performed with curative intent. REFERENCES 1. Cahan WG, Watson WL, Pool JL. Radical pneumonectomy. J Thorac Surg 1951;22:449–473. 2. Cahan WG. Radical lobectomy. J Thorac Cardiovasc Surg 1960;39:555–572. 3. The National Cancer Center. Tokyo, Japan. Undated brochure; p. 10. 4. Naruke T, Suemasu K, Ishikawa S. Surgical treatment for lung cancer with metastasis to mediastinal lymph nodes. J Thorac Cardiovasc Surg 1976;71:279–285. 5. Naruke T, Tsuchiya R, Kondo H, Nakayama H, Asamura H. Lymph node sampling in lung cancer: how should it be done? Eur J Cardiothorac Surg 1999;16 Suppl 1:S17–S24. 6. Mountain CF. Biologic, physiologic, and technical determinants in surgical therapy for lung cancer. In: StrausMJ, (Ed.). Lung Cancer. Clinical diagnosis and treatment. 2nd edition. New York:Grune & Stratton;1983; Pp.245–260. 7. Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978;76:832–839. 8. Rami-Porta R, Wittekind C, Goldstraw P; International Association for the Study of Lung Cancer (IASLC) Staging Committee. Complete resection in lung cancer surgery: proposed definition. Lung Cancer 2005;49:25–33. 9. Lardinois D, De Leyn P, Van Schil P, et al. ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer. Eur J Cardiothorac Surg 2006;30:787–792. 10. Osarogiagbon RU, Yu X. Mediastinal lymh node examination and survival in resected early stage non-small cell lung cancer in the Surveillance, Epidemiology and End Results database. J Thorac Oncol 2012;7:1798–1806. 11. Pignon JP, Tribodet H, Scagliotti GV, et al.; LACE Collaborative Group. Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group. J Clin Oncol 2008;26:3552–3559. 12. Grupo Cooperativo de Carcinoma Broncogénico de la Sociedad Española de Neumología y Cirugía Torácica (GCCB-S). Estadificación ganglionar intraoperatoria en la cirugía del carcinoma broncogénico. Documento de consenso. Arch Bronconeumol 2001;37:495–503. 13. Brunelli A, Dahan M, Decaluwe HMA et al; European Society of Thoracic Surgeons. Thoracic Database. Ancona, Italy: Tecnoprint Editrice srl, 2012. p. 41. 14. Goldstraw P (Ed). Staging Manual in Thoracic Oncology. Orange Park, FL: Editorial Rx Press, 2009. Pp. 82–83. 15. Goldstraw P. Report on the international workshop on intrathoracic staging. London, October 1996. Lung Cancer 1997;18:107–111. 16. Osarogiagbon RU, Allen JW, Farooq A, Wu JT. Objective review of mediastinal lymph node examination in a lung cancer resection cohort. J Thorac Oncol 2012;7:390–396. 17. Ramirez RA, Wang CG, Miller LE, et al. Incomplete intrapulmonary lymph node retrieval after routine pathologic examination of resected lung cancer. J Clin Oncol 2012;30:2823–2828. 18. Osarogiagbon RU, Miller LE, Ramirez RA, et al. Use of a surgical specimen-collection kit to improve mediastinal lymph-node examination of resectable lung cancer. J Thorac Oncol 2012\;7:1276–1282.

Copyright © 2012 by the International Association for the Study of Lung Cancer