A Lobectomy by Any Other Name

There is growing recognition that not all lobectomies for lung cancer are the same. The components of the lobectomy treatment process are numerous, making it difficult to study lobectomy as a single treatment modality. Each of the lobectomy components must be viewed as having a potentially important influence on quality of life and survival. Aspects that are important include patient selection, particularly, finding a patient who is medically fit to withstand the surgical procedure and who has been thoroughly assessed by noninvasive or minimally invasive means to rule out metastatic disease. In addition, patients and their support system should be emotionally prepared for the procedure and the postoperative issues that arise. The surgeon must be thoroughly trained, educated, skilled, and focused to perform the most appropriate procedure to provide the best outcome: the best shortand long-term survival with the least probability of morbidity and debility. The medical center in which the procedure is performed must have the appropriate equipment, environment, and an educated, skilled, and interested medical and support staff (including the pathology team) to provide safe and quality intraand postoperative recovery. Such medical centers should regularly assess their quality indicators to make certain that they are delivering the highest quality of care. And once the patients are discharged, they should be provided access to ongoing support for their immediate and longterm recovery and a standardized means of evaluation for recurrence and management, if recurrence occurs. For a successful outcome, there is a large group of professionals that must be coordinated to perform the procedure correctly and safely. So, how are we doing? Little et al found that fewer than half of the surgical teams in the United States are performing adequate staging and lung cancer resection. Differences are noted in technique and procedure quality indicators. High-volume hospitals seem to have superior results. There are differences in specialty as well, with thoracic-trained and -focused surgeons having better results compared with general surgeons and cardiac surgeons. There are evidence-based recommendations available to surgical teams, but there is no method to determine if the guidelines are being followed. To evaluate one aspect of the lobectomy, Ramirez et al at the University of Tennessee in Memphis made an important observation, namely, that patients with early-stage lung cancer in the Memphis area seem to be understaged as a result of both the surgical technique used as well as the management of the specimen by the pathology laboratories. In previous studies, the authors reported that there were deficiencies that occurred in the operating room, and they found that by making minor changes in the process, they could improve certain aspects of surgical staging. In the article that accompanies this editorial, the authors present their evaluation of the method in which pathology handles the specimens. A prospective study was performed in which each patient served as his or her own control to determine whether a more extensive pathologic evaluation would not only render more lymph nodes, but would identify metastatic or possibly more metastatic disease than already present and result in upstaging. The authors did find an average of 11% more lymph nodes in 90% of the patients. In patients who were previously thought to have N0 disease, 12% were found to have unexpected lymph node metastases and undetected satellite nodules and thus were upstaged. These were patients who would likely benefit from adjuvant therapy. Unlike the rest of the lung cancer management process, the method in which a resected lobe and the accompanying tissues are managed by the pathologist is not standardized. It seems that there are two parallel universes, that of the treatment group and that of the group assessing the pathology. Despite the fact that the International Association for the Study of Lung Cancer has improved the staging system by increasing the number of patients and number of institutions submitting cases and performing a thorough statistical analysis, the lack of a consistent approach to evaluation of the surgical specimen likely introduces significant variability in the staging process. To help improve the quality of lung cancer surgery, referring physicians and cancer specialists should critically review operative and pathology reports. Did the patient really have a lobectomy? The elements that should be included in the reports are individual ligation of the bronchus and the vasculature. All of the hilar nodes should be resected or sampled and there should be a thorough assessment of four or more mediastinal lymph node stations, including a contralateral nodal station. Ten to sixteen lymph nodes should be evaluated by the surgeon/pathology team. There should be an R0 resection, that is, no tumor, gross or microscopic, at the margin of resection. Pneumonectomy should be the last option for treatment, with every effort made to preserve the parenchyma. Hopefully, with higher expectations, there will be greater consistency in the performance of lobectomies and we will have a better understanding of the role of this procedure in the treatment of non–small-cell lung cancer.