Rebuttal From Dr DetterbeckRebuttal from Dr Detterbeck FREE TO VIEW

Frank C. Detterbeck, MD, FCCP
Author and Funding Information

Department of Surgery, Division of Thoracic Surgery, Yale University School of Medicine.

Correspondence to: Frank C. Detterbeck, MD, FCCP, Yale University School of Medicine, Thoracic Surgery, 330 Cedar St, BB205, New Haven, CT 06520-8062; e-mail: Frank.detterbeck@yale.edu

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):593-594. doi:10.1378/chest.11-3111
Text Size: A A A
Published online

The main arguments Dr Donington1 makes in favor of limited resection are that the current nature of non-small cell lung cancer (NSCLC) differs from the Lung Cancer Study Group era (and now includes subgroups for whom limited resection is best) and that modern recurrence and survival rates after sublobar resection are good, comparable to traditional data following lobectomy. I certainly agree that the spectrum of NSCLC currently includes more patients with less aggressive and relatively indolent tumors, and I agree that more limited treatment (ie, sublobar resection, stereotactic body radiotherapy, radiofrequency ablation) or even observation might sometimes be appropriate. I only disagree that we have defined either the patient selection or the treatment well enough. We certainly have not defined them well enough to recommend limited resection as a general approach for stage I NSCLC.

I concede the point that sublobar resection preserves pulmonary function well. However, because we are not talking about patients with limited pulmonary reserve, this argument has limited impact; the average patient tolerates a lobectomy without significant functional impairment. Furthermore, the morbidity of modern lobectomy (especially via thoracoscopy) is generally acceptably low.

The question of elective sublobar resection is not so much a physiologic question of how the patient will tolerate surgery as an oncologic question regarding long-term outcomes. Unfortunately, clinical science is messy, because many relevant factors are difficult to measure or unknown. This is the problem with series such as those Dr Donington presents in Table 1 of her editorial.1 It is exactly because of multiple factors that are changing simultaneously that I believe we need data from ongoing randomized trials (which Dr Donington also supports, while at the same time arguing that sublobar resection should be the standard for stage IA NSCLC).

A worthy argument is that outcomes with sublobar resection for specific groups of patients are so good that we do not need to do any better (ie, with lobectomy). However, first of all, this is an argument for specific subgroups, not in general for patients with stage I disease. Second, we still have questions to sort out regarding exactly how a subgroup is defined or whether the data we have apply to the patient in our clinic today (eg, can we expect the same outcomes in the United States as seen in series from Asia?). Finally, the results beg the question of whether simple observation might be appropriate for specific subgroups (eg, for adenocarcinoma in situ, minimally invasive adenocarcinoma, or pure ground-glass opacities).

I agree that it is worthwhile to ask whether sublobar resection is appropriate today for patients with stage cIA disease or whether we can define specific subgroups of patients for whom this is appropriate, but I disagree that we already know the answers to these questions at this time. I do not think it is appropriate to broadly apply sublobar resection as a therapeutic alternative in centers that are not carrying out research to accurately define the patient selection and treatment outcomes relative to alternative interventions.


Donington JS. Point: are limited resections appropriate in non-small cell lung cancer? Yes. Chest. 2012;1413:588-590. [PubMed] [CrossRef]




Donington JS. Point: are limited resections appropriate in non-small cell lung cancer? Yes. Chest. 2012;1413:588-590. [PubMed] [CrossRef]
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
Pemetrexed for the first-line treatment of non-small-cell lung cancer.
National Institute for Health and Clinical Excellence (NICE)
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543