INVITED COMMENTARY

Abstract

The importance of clinical staging for malignant disease cannot be overstated. Accurate clinical staging is a necessary prerequisite for treatment planning, prognostication, and for the rational design of clinical trials. The designation of a cTNM stage should incorporate all the information derived before thoracotomy from clinical evaluation, various imaging modalities, and invasive staging procedures such as mediastinoscopy. Ideally, clinical staging modalities should result in a cTNM stage that is highly predictive of the final pathologic stage as determined by pathologic examination of the excised lung parenchyma and the mediastinal lymph nodes. Unfortunately, clinical staging of non-small-cell lung cancer (NSCLC) falls short of that ideal. The degree of correlation between clinical and pathological staging varies between 35% and 50%. López-Encuentra and his colleagues compare clinical and pathologic staging in nearly 3000 cases of NSCLC that represent nearly 50% of all lung cancer cases operated on in Spain between 1993 and 1997. The authors should be commended for their huge effort, because this is probably the largest series to date that addresses this issue and is likely the most current. Sadly, however, the news is not good. Nearly a decade and several generations of computed tomography (CT) scanners after prior similar studies, the accuracy of clinical staging in predicting the final pTNM stage remains poor. In the current report it is less than 50%. Unfortunately, clinical staging in their study did not include positron emission tomography (PET) scanning, which is rapidly becoming a common procedure in the United States, though perhaps not in Europe. The authors appropriately acknowledge this limitation of the study and conclude that this series should represent an adequate historical control for future studies that use PET scanning. The reader may be tempted, however, to conclude that the poor correlation merely reflects a lack of consistent use of mediastinoscopy. For example, 20% and 30% of patients clinically designated as having stages IA and IB, respectively, proved to have stage III disease and potentially did not benefit from primary resection. Similarly, approximately 20% of patients designated as stage IIIA and IIIB had earlier stages and may have been denied operative intervention. Given the suboptimal accuracy of CT scans in predicting nodal metastases, a more liberal application of mediastinoscopy could have added significantly to the accuracy of clinical staging. In an ideal world we should consistently use all of the modalities at our disposal to clinically stage patients with NSCLC. Only then will we establish a reliable historical control. Comparison Between Clinical and Pathologic Staging in 2,994 Cases of Lung CancerThe Annals of Thoracic SurgeryVol. 79Issue 3PreviewThe accuracy of clinical staging in lung cancer may be evaluated by comparing it against the gold standard of pathologic staging. The objective of this paper is to compare these two staging methods in a series of 2,994 lung cancer cases operated on consecutively in Spain between 1993 and 1997. Full-Text PDF