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The “Goldilocks” Principle FREE TO VIEW

Alex G. Little, MD, FCCP
Author and Funding Information

Affiliations: Dayton, OH
 ,  Dr. Little is Elizabeth Berry Gray Chair and Professor, Wright State University Department of Surgery.

Correspondence to: Alex G. Little, MD, FCCP, 1 Wyoming St, Suite 7000 WCHE, Dayton, OH 45409; e-mail: alex.little@wright.edu

Chest. 2005;128(1):13-14. doi:10.1378/chest.128.1.13
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Published online

The article by Jaklitsch and colleagues (see page 237) is an important contribution to the challenge of making appropriate surgical decisions in the care of patients with non-small cell lung cancer (NSCLC). To use “Goldilocksian” analysis, the challenge for thoracic surgeons is to get the operation neither too hot (a resection of more lung than necessary) nor too cold (an insufficient resection), but to get it just right.

To put this issue into perspective, through the first decades of the twentieth century there were only a few, anecdotal reports of lung resection for lung cancer. The description by Graham and Singer1 in 1993 of the performance (and not unimportantly the patient’s survival) of the first pneumonectomy for lung cancer established a role for surgical resection in the treatment of lung cancer patients. In fact, surgical resection became relatively standard with pneumonectomy being the cancer operation of choice. Over time, however, experience has showed that an anatomic lobectomy was technically feasible and resulted in the same outcomes as the more extensive operation, for patients with a similar stage of disease, if the primary tumor was limited to a lobe. This then resulted in a transition in the thoracic surgery community to lobectomy as the preferred procedure to preserve the maximum amount of pulmonary reserve. At present, pneumonectomy is reserved for patients with such centrally located cancers that even the technique of sleeve resection does not allow a lobectomy to encompass all disease. Resections less than lobectomy, which leave behind intrapulmonary lymphatics as well as parenchyma, such as wedge resection and segmentectomy have been generally considered to be marginally or completely inadequate cancer procedures and employed sparingly and selectively for patients with limited pulmonary reserve and/or comorbid conditions leading to the assessment of the patient as a poor candidate for a “major” operation.

The authors used a large database to accumulate and analyze 14,555 patients with stage 1 or 2 NSCLC who were operated on for cure with either a lobectomy or one of the lesser resections. Their comparative analysis has convincingly demonstrated that for patients with early stage lung cancer (definitely stage 1 patients and probably stage 2 patients), a lobectomy remains the operation of choice for those patients < 71 years old. Below this age, the survival curve for lobectomy patients is significantly better than that for a lesser resection. This would be considered old news. However, the new information is that the survival curves are similar above the age of 71 regardless of the operative procedure. In other words, patients > 71 years of age treated with lobectomy compared to patients treated with a limited resection did not receive a survival benefit. Survival following operation was quite similar whether the patient received either of these operative alternatives.

This information is compelling, and it will certainly influence my selection of operation for elderly patients with stage 1 NSCLC. Knowing there is no cancer survival benefit for the patient from a lobectomy, the choice is a wedge resection that is less morbid because it is technically simpler, resulting in a shorter operation with less risk of blood loss, and maximizes the remaining lung volume.

A few caveats need to be identified. First, a limited resection, be it a wedge resection or a segmentectomy, must be a sufficient cancer operation as defined by the authors. That is, the margins of the surgical specimen must be free of cancer. This must be determined by frozen section analysis at the time of operation, and if there is any question of residual disease being left behind then further lung tissue must be resected. A limited resection with cancer in the margin of resection cannot be considered to be a sufficient cancer operation. This means that if this criterion cannot be met in older patients with large and/or sufficiently proximal primary cancers, then a lobectomy should be performed in the absence of physiologic contraindications.

My second caveat is that while the authors have demonstrated that on a population basis there is an age-dependent transition in the risk/benefit ratio favoring a “lesser” operation above age 71 years, I have to believe that individual patients may have specific characteristics that would legitimately affect surgical decision making. For example, the quite healthy, otherwise-free-of-disease older patient who stopped smoking 10 years earlier and has an excellent performance status might well be considered to have sufficient longevity, so that the more complete cancer operation, the lobectomy, would be preferred. There is, in other words, still the need for the art as well as the science of medicine to be practiced so that the surgical treatment for the patient is “just right.”


Graham, EA, Singer, JJ (1933) Successful removal of the entire lung for carcinoma of the bronchus.JAMA101,1371-1375. [CrossRef]




Graham, EA, Singer, JJ (1933) Successful removal of the entire lung for carcinoma of the bronchus.JAMA101,1371-1375. [CrossRef]
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