Invited commentary

Abstract

The management of patients with small, peripheral lung cancers, but with very limited pulmonary reserve or other serious co-morbid conditions, continues to be a formidable challenge. Several large series have concluded that segmental and/or wedge resections of stage I lung cancers (excluding small cell carcinoma) are associated with a higher incidence of local/regional recurrence when compared with patients with similar tumors undergoing a lobectomy. I agree with others that for patients with clinical stage I lung cancer, “less-than lobectomy” resections should be reserved for compromised patients. In the current paper, the authors have added their voices to the growing chorus advocating the option of implanting brachytherapy seeds along the pulmonary resection margins in an attempt to limit local recurrence. This is an intuitively attractive idea, and apparently can be performed safely. However, this strategy focuses only on those cancer cells remaining undetected in the surrounding lung parenchyma. The possibilities of “drop metastases” in the pleural space to a remote sites on the surface of the lung, implants into the wound (especially port sites), and recurrences arising from tumor cells in the parenchymal lymphatics and in unresected bronchopulmonary or mediastinal nodes are other manifestations of recurrent tumor that would not be addressed. Indeed, when faced with only a CT scan and a positive needle aspirate, it can be difficult if not impossible to establish the spatial relationship between the recurrent tumor and the original margin of resection. This is precisely why, in our paper, I defined local/regional recurrence so broadly. Had we not done so, another reviewer of our clinical experience could have concluded that segmental resections predispose to a high incidence of second primary tumors, since many were judged to be remote from the pulmonary resection margin. I agree with the author’s conclusion. Establishing whether or not brachytherapy reduces the incidence of local recurrence will require a larger collection of carefully selected patients studied and followed for several years.