Lung Cancer, Histologic Stratification, and Resection Extent: Something for Surgeons to Think About

Extract

You would think that thoracic surgeons have plenty to consider when planning for a lung cancer resection in 2013. We have been bombarded with “the small nodule” less than 2mm, which we have learned can have various inhomogeneities in its computerized tomographic (CT) analysis ( 1 ); we have to decide whether the nodule merits a lobectomy (the standard of care) or a sublobar resection ( 2 ) (for those heretics in the minority who feel that we don’t need a randomized trial to answer the sublobar vs lobectomy debate); whether we should mark the nodule preoperatively so we will be able to find it because we are sometimes trying to feel a 2-cm sponge within a giant sponge; and whether to perform the case as a video-assisted resection, a robotic resection, or (shudder) as an open procedure with rib resection/spreading. As if those deliberations were not enough, now we must start to worry about whether the (presumed lung cancer) solid or part-solid nodule presented to us on the CT scan has a critical quantifiable element of micropapillary disease, which may be associated with tumor recurrence if we do a wedge resection or a segmentectomy (which, of course, will only be the standard of care for intentional lung cancer resections if this is confirmed by the results of CALGB 140503 “A Phase III Randomized Trial of Lobectomy Versus Sublobar Resection for Small (<2cm) Peripheral Non–Small Cell Lung Cancer” ( 3 ).