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Rebuttal From Dr DoningtonRebuttal from Dr Donington

Jessica S. Donington, MD
Author and Funding Information

Department of Cardiothoracic Surgery, NYU School of Medicine.

Correspondence to: Jessica S. Donington, MD, Department of Cardiothoracic Surgery, NYU School of Medicine, 530 First Ave, Ste 9V, New York, NY 10016; e-mail: Jessica.Donington@nyumc.org


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential 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 (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2012 American College of Chest Physicians


Chest. 2012;141(3):592-593. doi:10.1378/chest.11-3109
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Dr Detterbeck1 is correct in defending results from randomized trials as the gold standard for advances in medicine. But randomized data are often slow to evolve and can be flawed by trial design or data acquisition. Therefore, improvements in care are frequently made without the benefit of randomized data. This in no way indicates that the ongoing Cancer and Lymphoma Group B trial (CALBG 140503)2 evaluating the use of sublobar resection for small peripheral stage IA tumors is not needed. Data from this trial should serve as a modern benchmark for the treatment of stage IA non-small cell lung cancer (NSCLC) and guide surgical care for decades to come. But the trial is accruing slowly, and it will be many years before any conclusions can be made. In the meantime, there is a growing mountain of nonrandomized data that indicate a need for a change in the surgical mindset with regard to the use of segmentectomy for small peripheral NSCLC. Our understanding of NSCLC biology has advanced dramatically over the past decade. Stage IA NSCLCs are no longer viewed as a homogeneous group with a uniform prognosis, and surgical management should also not be so rigid and methodical. Segmentectomy needs to be a consideration when contemplating resection of a small (<2 cm) peripheral lesion that lies within a segmental boundary. Potential trial candidates should be enrolled in CALGB 140503, and for those who are not, segmentectomy should be at least placed into the discussion, especially if ineligibility is due to medical comorbidity.

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