Abstract
Simple SummaryIn the surgical treatment of lung cancer, the complete removal of the portion of the lung where the cancer is and of the involved adjacent structures is of paramount importance to achieve long-term survival. The International Association for the Study of Lung Cancer (IASLC) proposed a definition of complete resection that included a well-defined type of removal of the regional lymph nodes as a fundamental step. The lymph nodes may contain cancer cells and, if left behind, cancer will soon progress. The IASLC also defined incomplete resection when there is any evidence of persistent cancer after the operation. It also defined an intermediate condition, uncertain resection, when no evidence of residual disease can be proved, but all the conditions of complete resection are not fulfilled. Four validations of the definitions have proved their prognostic value and, therefore, the definitions should be followed when a surgical resection of lung cancer is planned.Different definitions of complete resection were formulated to complement the residual tumor (R) descriptor proposed by the American Joint Committee on Cancer in 1977. The definitions went beyond resection margins to include the status of the visceral pleura, the most distant nodes and the nodal capsule and the performance of a complete mediastinal lymphadenectomy. In 2005, the International Association for the Study of Lung Cancer (IASLC) proposed definitions for complete, incomplete and uncertain resections for international implementation. Central to the IASLC definition of complete resection is an adequate nodal evaluation either by systematic nodal dissection or lobe-specific systematic nodal dissection, as well as the integrity of the highest mediastinal node, the nodal capsule and the resection margins. When there is evidence of cancer remaining after treatment, the resection is incomplete, and when all margins are free of tumor, but the conditions for complete resection are not fulfilled, the resection is defined as uncertain. The prognostic relevance of the definitions has been validated by four studies. The definitions can be improved in the future by considering the cells spread through air spaces, the residual tumor cells, DNA or RNA in the blood, and the determination of the adequate margins and lymphadenectomy in sublobar resections.
Highlights
The Workshop concluded by establishing three main objectives: (1) the creation of a Staging Committee, later renamed Staging and Prognostic Factors Committee (SPFC), with the responsibility to collect an international database of lung cancer patients treated with all types of therapeutic modalities to inform future editions of the TNM classification of lung cancer; (2) the formulation of an international and multidisciplinary definition of complete resection; and (3) the design of a pulmonary and mediastinal lymph node map to reconcile the differences between the Naruke and the Mountain and Dresler maps that could be used internationally
Carcinoma in situ at the bronchial resection margin and positive pleural lavage cytology were excluded from the R0(un) category by the Union for International Cancer Control (UICC) because they already had been coded as incomplete resections: R1(is) [36] and R1(cy+) [35], respectively
There are new issues that should be integrated into future refinements of the definition, such as spread through air spaces (STAS), tumor cells or their DNA and RNA identified in the patients’ blood, and the minimal margins and adequate lymphadenectomy for sublobar resections
Summary
Nine years later, in 1960, Cahan described radical lobectomy—the removal of a lobe with specific lymphadenectomy depending on the lobar location of the primary tumor—and stated that radical lobectomy should be reserved for those patients who could not undergo radical pneumonectomy [4] It was not considered an oncologically sound operation at that time, by the end of the decade, radical lobectomy had gained credit as a consolidated operation for lung cancer [5]. The mapping of the pulmonary and mediastinal lymph nodes, first published by Tsuguo Naruke in 1967 in Japanese [7] and subsequently in English [8,9] was instrumental for the understanding of the prognostic impact of nodal disease This map was the forerunner of all the other maps proposed to date by the American Thoracic Society [10], by Mountain and Dresler [11] and by the International Association for the Study of Lung. Starting from the historical background described above, this perspective article will review the evolution of the concept of complete resection in the surgical treatment of lung cancer
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