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Eur J Cardiothorac Surg 2007;32:29-34. doi:10.1016/j.ejcts.2007.04.003
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
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a Department of Surgery, Tergooiziekenhuis, Hilversum, The Netherlands
b Department of Pulmonology, Free University Medical Centre, Amsterdam, The Netherlands
c Department of Radiotherapy, Free University Medical Centre, Amsterdam, The Netherlands
Received 23 January 2007; received in revised form 21 March 2007; accepted 2 April 2007.
* Corresponding author. Address: Academic Medical Centre, Department of Surgery, Location G4-146, Post Box 22660, 1100 DD Amsterdam, The Netherlands. Tel.: +31 20 5663170; fax: +31 20 6914858. (Email: j.wind{at}amc.uva.nl).
The most important surgical goal during potentially curative surgery for non-small cell lung cancer (NSCLC) is a macroscopic and microscopic radical resection (R 0-resection). Studies reporting on recurrence and long-term survival mainly comprise patients with completely resected NSCLC (R 0-resection). However, there is limited data on incidence, treatment and prognosis of patients with microscopic residual tumour tissue at the bronchial resection margin (R 1-resection). Furthermore, the definition of an R 1-resection of the bronchial resection margin is not uniform in literature. Based on 19 studies published between 1945 and 2003 with a substantial number of included patients with resected NSCLC, the incidence of an R 1-resection of the bronchial resection margin is approximately 4–5% (range 1.2–17%) of all lung resections. Divided into the localisation of the microscopic residual disease, survival of patients with carcinoma in situ (CIS) at the bronchial resection margin is comparable to the survival after a radical resection. The prognosis is negatively influenced in case of microscopic mucosal residual disease. Survival is even worse in patients with peribronchial residual disease; 1- and 5-year survivals range between 20–50% and 0–20%, respectively. This poor prognosis is because peribronchial residual disease, in 75–85% of the patients, is associated with mediastinal lymph node metastasis. According to the stage, survival of patients with stage I and II NSCLC and an R 1-resection of the bronchial resection margin is significantly worse as compared to stage-corrected survival after a radical resection. In these patients, survival is limited due to local recurrence. The negative effect of an R 1-resection of the bronchial margin in stage III NSCLC is limited, as these patients die due to disseminated disease (distant metastasis) before local recurrence occurs. A conservative approach with frequent bronchoscopic surveillance is justified for CIS. For patients with microscopic residual disease at the bronchial margin and stage I and II NSCLC, further treatment has to be considered. Adjuvant treatment in patients with stage III NSCLC has no proven benefit in terms of survival.
Key Words: Microscopic residual disease • R 1-resection • Bronchial resection margin • Non-small cell lung cancer
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