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Sai-Hong Ignatius Ou, MD, PhD; Jason A. Zell, DO, MPH
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University of California Irvine Medical Center Orange, CA

Correspondence to: Sai-Hong Ignatius Ou, MD, PhD, Chao Family Comprehensive Cancer Center, UC Irvine Medical Center, Medicine, 101 The City Dr, Building 56, RT81, Room 241, Orange, CA 92868-3298; e-mail: siou@uci.edu


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):1695-1696. doi:10.1378/chest.09-0406
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To the Editor:

We thank Hung et al for their thoughtful and insightful comments, and agree with their interpretation of our results.1 While we could not individually separate the three major non–size-based criteria (visceral pleural invasion, hilar atelectasis, and obstructive pneumonitis), Jones et al (reference 16 in our article2) have clearly indicated that hilar atelectasis and obstructive pneumonitis rarely are the only criteria for staging non-small cell lung cancer as stage 1B.

Hung et al raised the possibility that our finding that T2P tumors > 3 cm in size is a poor independent prognostic factor for survival because these patients may have T2S tumor sizes much > 3 cm. From our patient database, the mean tumor size for patients with T2P tumors > 3 cm was 5.15 cm (median size, 4.5 cm; 95% confidence interval, 3 to 9 cm) and the mean tumor size of patients with T2S tumors > 3 cm was 5.07 cm (median size, 4.5 cm; 95% confidence interval, 3.2 to 8.5 cm; p = 0.4595 [nonparametric t test]). Thus, it is unlikely that the independent unfavorable prognostic significance of T2P tumors > 3 cm in size in our study is due to larger tumor size.

Another finding in our study1 was that patients with T2P tumors ≤ 3 cm in size had similar survival times to those with T2S tumors ≤ 3 cm and T2P tumors ≤ 3 cm in size was an independent favorable prognostic factor, thus raising another question about whether the designation T2P should even be applied to tumors ≤ 3 cm. As stated by Travis et al3 (page 1387) on behalf of the International Association for the Study of Lung Cancer (IASLC) International Staging Committee (ISC) “the question of the effect of tumor size on the impact of visceral pleural invasion remains to be determined in studies of larger numbers of cases such as the prospective IASLC database” and “Study of larger numbers of cases with careful documentation of visceral pleural invasion will hopefully provide an answer to the question whether size has any impact on the significance of this T factor … … Hopefully these issues will be resolved in the prospective IASLC lung cancer staging project”3 (page 1389). Thus, it is not only worthwhile to perform an analysis to determine the prognostic significance of the T2P designation according to the newly proposed T factor sizes > 3 and ≤ 5 cm (T2a), > 5 and ≤ 7 cm (T2b), and > 7 cm (T3), but is also worthwhile to conduct such an analysis for tumor sizes ≤ 2 cm (T1a), > 2 cm, and ≤ 3 cm (T1b).

Ou S-HI, 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;133:552-669. [PubMed] [CrossRef]
 
Jones DR, Daniel TM, Denlinger CE, et al. Stage IB nonsmall cell lung cancers: are they all the same? Ann Thorac Surg. 2006;81:1958-1962. [PubMed]
 
Travis WD, Brambilla E, Rami-Porta R, et al. Visceral pleural invasion: pathologic criteria and use of elastic stains; proposal for the 7th edition of the TNM classification for lung cancer. J Thorac Oncol. 2008;3:1383-1390
 

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References

Ou S-HI, 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;133:552-669. [PubMed] [CrossRef]
 
Jones DR, Daniel TM, Denlinger CE, et al. Stage IB nonsmall cell lung cancers: are they all the same? Ann Thorac Surg. 2006;81:1958-1962. [PubMed]
 
Travis WD, Brambilla E, Rami-Porta R, et al. Visceral pleural invasion: pathologic criteria and use of elastic stains; proposal for the 7th edition of the TNM classification for lung cancer. J Thorac Oncol. 2008;3:1383-1390
 
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