Invited commentary

Abstract

Doctor Ichinose and colleagues opportunely point out several current controversial topics: (1) benefit of surgery in stage IIIB disease; (2) feasibility of surgical resection after CRT; (3) rationale of using UFT (a combination of Tegafur and Uracile) concurrently with Cisplatin and radiation therapy; (4) relevance of the T4 descriptor in present staging system; (5) coherence of team skills for multicentric trials. Stage IIIB disease includes several situations in which surgical resection can be performed as an adjuvant local control after CRT. This is currently shown and particularly quoted in the paper by Ichinose and colleagues. For instance, our study found a 5-year survival rate of 28% following surgery in patients who were not controlled by CRT [1Grunenwald D.H. André F. Le Péchoux C. et al.Benefit of surgery after chemoradiotherapy in stage IIIB (T4 and/or N3) non-small cell lung cancer.J Thorac Cardiovasc Surg. 2001; 122: 796-802Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar]. Feasibility of surgical resection after CRT has been demonstrated in numerous phase II studies, and confirmed in a large multicenter randomized trial in North America [2Albain KS, Scott CB, Rusch VR, et al. Phase III comparison of concurrent chemotherapy (CT/RT) and CT/RT followed by surgical resection for stage IIIA (pN2) non-small cell lung cancer (NSCLC): initial results from intergroup trial 0139 (RTOG 93-09). Proceedings of the ASCO 2003;A2497Google Scholar]. Improvement of surgical outcome in attempting to avoid the 4%–5% postoperative mortality would involve a large number of specialists together because such a multidisciplinary approach is teamwork, including anaesthesiologists and ICU physicians. Doctor Ichinose and colleagues used an original combination of UFT and Cisplatine concurrently with radiotherapy as an induction strategy. UFT is an oral, well-tolerated antimetabolite, which was proven effective in previous trials. An impressive 5-year survival benefit (11%) was found for T2N0 adenocarcinomas in a large randomized trial of adjuvant UFT [3Kato H, Tsuboi M, Ohta M, et al. A randomized phase III trial of adjuvant chemotherapy with UFT for completely resected pathological stage 1 (T1N0M0, T2N0M0) adenocarcinoma of the lung. Proceedings of the ASCO 2003;A2498Google Scholar]. Interestingly, a majority of patients in Dr Ichinose's study had adenocarcinomas. These findings could raise the question of biological similarities between colon cancer and lung adenocarcinoma. A major issue is relevance of T4 descriptor in the current staging system, according to recent surgical advances. Since 1974, the staging system for NSCLC has paradigmatically divided the patients into two groups according to the surgical resectability [4Mountain C.F. Carr D.T. Anderson W.A.D. A system for the clinical staging of lung cancer.Am J Roentgenol. 1974; 120: 130-138Crossref Scopus (229) Google Scholar]. Surgery must be the crucial component to sort out different clinical presentations since it remains the only curative method. Actually, patients must be subdivided into three categories: (1) early stage who could be surgically cured; (2) advanced stage who will never meet a surgeon; (3) marginally resectable tumors. This latter category where upfront surgery is either not possible or unable to achieve a long-term prognosis is the ground for combined treatment modalities. But the landmarks between these therapeutic groups given by the current TNM descriptors are too imprecise and would deserve to be clarified. The French proposition suggests subdivision of T4 descriptor into two subgroups: (1) definitively nonresectable tumors, as oesophageal involvement, malignant pleural or pericardial effusion, bulky invasion of the heart, called T4-2; (2) other T4 cases, including left atrial, vascular, carinal, carinal, and even vertebral invasion, called T4-1, fit for induction strategies followed by surgery [5Grunenwald D.H. Surgery for advanced stage lung cancer.Semin Surg Oncol. 2000; 18: 137-142Crossref PubMed Scopus (27) Google Scholar]. Evolving concept of resectability for T4 tumors addresses the issue of homogeneity in team skills for clinical trials of multimodality treatment. In fact, aggressivity and ability of thoracic surgeons to perform extended resections are limited to several centers throughout the world.