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Correspondence |

The Effect of Tumor Size on Non–Size-Based Descriptors in Staging of Stage I Non-small Cell Lung Cancer FREE TO VIEW

Jung-Jyh Hung, MD; Jung-Sen Liu, MD, PhD; Yu-Chung Wu, MD; Wen-Hu Hsu, MD
Author and Funding Information

Affiliations: Cathay General Hospital Taipei, Taiwan,  National Yang-Ming University Taipei, Taiwan

Correspondence to: Wen-Hu Hsu, MD; e-mail: whhsu@vghtpe.gov.tw

*These authors contributed equally to this work.


The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).


© 2009 American College of Chest Physicians


Chest. 2009;135(6):1695. doi:10.1378/chest.08-2868
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To the Editor:

We read with great interest the study by Ou and colleagues1 recently published in CHEST (March 2008) highlighting the prognostic significance of non–size-based T2 descriptors in patients with stage I non-small cell lung cancer. The authors defined T2P as a descriptor of a T2 tumor in patients with visceral pleural invasion (VPI), hilar atelectasis, or obstructive pneumonitis in their study.1 They found that the T2P descriptor carried an increased mortality risk in patients with T2 tumors, but that this mortality risk was dependent on tumor size.

One of the major conclusions in the study by Ou and colleagues1 was that for patients with stage IB (T2N0M0) non-small cell lung cancer with a tumor size of > 3 cm, the T2P descriptor is a poor independent prognostic factor. The authors have acknowledged that a major limitation of their study was that VPI could not be separated from hilar atelectasis or obstructive pneumonitis. However, they presumed1 that the majority of patients within the T2P category had VPI. The effect of tumor size on the impact of VPI has rarely been demonstrated, and the results have remained controversial. Furthermore, the relationship between tumor size and frequency of VPI has rarely been investigated.2,3 Manac'h and colleagues2 have demonstrated that the frequency of VPI significantly increased as tumor size increased (tumors ≤ 3 cm, 10%; tumors > 3 to ≤ 5 cm, 19.6%; tumors > 5 cm, 33%). Shimizu and coworkers3 also reported that patients with tumors having a diameter of > 3 cm had a higher possibility of VPI. In the study by Ou and colleagues,1 the group of patients with T2 tumors > 3 cm with a T2P descriptor may consist of more patients with tumors of larger size than that of patients with T2 tumors > 3 cm alone. Therefore, the prognostic value of the T2P descriptor in T2 tumors > 3 cm may be partly contributed by larger tumor size. We wonder how Ou and colleagues1 handled the possible interaction of VPI and tumor size in their study.

The International Association for the Study of Lung Cancer lung cancer staging project committee has published proposals for the revision of the forthcoming seventh edition of the TNM classification of lung cancer.4,5 T2 tumors have been recommended to be classified into categories of T2a (tumors > 3 to ≤ 5 cm), T2b (tumors > 5 to ≤ 7 cm), and T3 (tumors > 7 cm).4 Non–size-based T2 descriptors have not been evaluated due to the small number of patients, inconsistent clinical and pathologic results, or lack of validation.4 Tumors in patients with VPI, hilar atelectasis, or obstructive pneumonitis have been proposed to be classified as T2a if the tumor size is ≤ 5 cm.5 Their recommendations suggest that tumor size is a better prognostic predictor than the presence of VPI, hilar atelectasis, or obstructive pneumonitis in the staging of non-small cell lung cancer tumors with larger diameters. We therefore raise another question for Ou and colleagues. Is the T2P descriptor still a significant prognostic factor in T2 tumors with tumor sizes of > 5 to ≤ 7 cm or > 7 cm?

Ou SH, Zell JA, Ziogas A, et al. Prognostic significance of the non–size-based AJCC T2 descriptors: visceral pleura invasion, hilar atelectasis, or obstructive pneumonitis in stage IB non-small cell lung cancer is dependent on tumor size. Chest. 2008;133:662-669. [PubMed] [CrossRef]
 
Manac'h D, Riquet M, Medioni J, et al. Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor. Ann Thorac Surg. 2001;71:1088-1093. [PubMed]
 
Shimizu K, Yoshida J, Nagai K, et al. Visceral pleural invasion is an invasive and aggressive indicator of non-small cell lung cancer. J Thorac Cardiovasc Surg. 2005;130:160-165. [PubMed]
 
Rami-Porta R, Ball D, Crowley J, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol. 2007;2:593-602. [PubMed]
 
Goldstraw P, Crowley J, Chansky K, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol. 2007;2:706-714. [PubMed]
 

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References

Ou SH, Zell JA, Ziogas A, et al. Prognostic significance of the non–size-based AJCC T2 descriptors: visceral pleura invasion, hilar atelectasis, or obstructive pneumonitis in stage IB non-small cell lung cancer is dependent on tumor size. Chest. 2008;133:662-669. [PubMed] [CrossRef]
 
Manac'h D, Riquet M, Medioni J, et al. Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor. Ann Thorac Surg. 2001;71:1088-1093. [PubMed]
 
Shimizu K, Yoshida J, Nagai K, et al. Visceral pleural invasion is an invasive and aggressive indicator of non-small cell lung cancer. J Thorac Cardiovasc Surg. 2005;130:160-165. [PubMed]
 
Rami-Porta R, Ball D, Crowley J, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the T descriptors in the forthcoming (seventh) edition of the TNM classification for lung cancer. J Thorac Oncol. 2007;2:593-602. [PubMed]
 
Goldstraw P, Crowley J, Chansky K, et al. The IASLC Lung Cancer Staging Project: proposals for the revision of the TNM stage groupings in the forthcoming (seventh) edition of the TNM Classification of malignant tumours. J Thorac Oncol. 2007;2:706-714. [PubMed]
 
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