0
Correspondence |

N2 Nodal Involvement in Multiple Primary Lung CancerN2 Nodal Involvement in Primary Lung Cancer: Really an Exclusion Criterion? FREE TO VIEW

Giovanni Leuzzi, MD; Alfredo Cesario, MD; Marco Chiappetta, MD; Stefano Margaritora, PhD; Venanzio Porziella, MD; Elisa Meacci, MD; Maria L. Vita, MD; Maria T. Congedo, MD; Pierluigi Granone, PhD
Author and Funding Information

From the Department of Thoracic Surgery (Drs Leuzzi, Cesario, Chiappetta, Margaritora, Porziella, Meacci, Vita, Congedo, and Granone), Catholic University of the Sacred Heart; and IRCCS San Raffaele Pisana (Dr Cesario).

Correspondence to: Giovanni Leuzzi, MD, Department of Thoracic Surgery, Catholic University of the Sacred Heart, Largo F. Vito n 1, 00168 Rome, Italy; e-mail: gio.leuzzi@yahoo.it


Financial/nonfinancial disclosures: The authors have 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. See online for more details.


Chest. 2013;144(2):714-715. doi:10.1378/chest.13-0758
Text Size: A A A
Published online
To the Editor:

Girard et al1 reported in CHEST (January 2010) a comparison analysis of seven patients with multiple lung adenocarcinomas benchmarked on the epidermal growth factor receptor (EGFR) and Kirsten-rat sarcoma 2 viral oncogene homolog clonality status, which we read with interest and has instigated some reflections. Martini-Melamed (MM) criteria outlined a clinical and diagnostic classification of multiple primary lung cancers (MPLCs)2; today, American College of Chest Physicians (ACCP) guidelines provided a new MPLC classification.3 Both MM and ACCP criteria are used to classify an MPLC case as primary metastatic or true synchronous/metachronous multiple. Furthermore, none of these criteria incorporate information on molecular status to distinguish multiple primary from metastatic disease. The new diagnostic algorithm described by Takamochi and colleagues4 is based on the assessment of EGFR-Kirsten-rat sarcoma 2 viral oncogene homolog to achieve a correct definition of the clonality status among multiple lung adenocarcinomas and, in turn, is used as a differential diagnosis criterion. With this algorithm, Takamochi and colleagues4 could easily detect significant discrepancies in existing clinical criteria in 36 patients they thoroughly examined to assess the difference between true primary and metastatic disease. Similar evidence was reported in Girard et al,1 thus, confirming the inherent limitations of the MM/ACCP criteria. Moreover, Takuwa et al5 advocated for molecular-based stratification criteria by detailing a case of multiple synchronous lung adenocarcinomas harboring an L858R mutation within exon 21 of EGFR in the middle-lobe tumor and subcarinal nodes but not in the upper-lobe tumor. In the setting where MM/ACCP criteria are taken into account, the diagnosis of N2 nodal involvement defines synchronous multiple tumors as metastatic lesions; however, these data might suggest that the number of multiple primary adenocarcinomas could be higher than what is observed if only MM/ACCP criteria are taken into account. On the other hand, very few reports compare the clonality status of primary tumors and lymph node metastases6: of 56 non-small cell lung cancers, the molecular appearance in the primary cancer and its lymph node metastasis were concordant in 92.9% and 69.6% by p53 and EGFR status, respectively.

According to the high concordance between the clonality of primary tumors with metastatic spread to the lymph nodes, it could be suggested that, in the case of multiple adenocarcinomas, a clonality status evaluation in the mediastinal lymph node metastasis should also be performed. We would appreciate the authors’ opinion about whether the assessment of the clonal lymph node status of their series of seven patients would be a valuable piece of information.

References

Girard N, Deshpande C, Azzoli CG, et al. Use of epidermal growth factor receptor/Kirsten rat sarcoma 2 viral oncogene homolog mutation testing to define clonal relationships among multiple lung adenocarcinomas: comparison with clinical guidelines. Chest. 2010;137(1):46-52. [CrossRef]
 
Martini N, Melamed MR. Multiple primary lung cancers. J Thorac Cardiovasc Surg. 1975;70(4):606-612.
 
Shen KR, Meyers BF, Larner JM, Jones DR; American College of Chest Physicians. Special treatment issues in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3)(suppl):290S-305S.
 
Takamochi K, Oh S, Matsuoka J, Suzuki K. Clonality status of multifocal lung adenocarcinomas based on the mutation patterns of EGFR and K-ras. Lung Cancer. 2012;75(3):313-320. [CrossRef]
 
Takuwa T, Tanaka F, Yoneda K, et al. Diagnosis of synchronous primary lung adenocarcinomas based on epidermal growth factor (EGFR) gene status: a case report. Lung Cancer. 2010;68(3):498-500. [CrossRef]
 
Chang YL, Wu CT, Shih JY, Lee YC. Comparison of p53 and epidermal growth factor receptor gene status between primary tumors and lymph node metastases in non-small cell lung cancers. Ann Surg Oncol. 2011;18(2):543-550. [CrossRef]
 

Figures

Tables

References

Girard N, Deshpande C, Azzoli CG, et al. Use of epidermal growth factor receptor/Kirsten rat sarcoma 2 viral oncogene homolog mutation testing to define clonal relationships among multiple lung adenocarcinomas: comparison with clinical guidelines. Chest. 2010;137(1):46-52. [CrossRef]
 
Martini N, Melamed MR. Multiple primary lung cancers. J Thorac Cardiovasc Surg. 1975;70(4):606-612.
 
Shen KR, Meyers BF, Larner JM, Jones DR; American College of Chest Physicians. Special treatment issues in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3)(suppl):290S-305S.
 
Takamochi K, Oh S, Matsuoka J, Suzuki K. Clonality status of multifocal lung adenocarcinomas based on the mutation patterns of EGFR and K-ras. Lung Cancer. 2012;75(3):313-320. [CrossRef]
 
Takuwa T, Tanaka F, Yoneda K, et al. Diagnosis of synchronous primary lung adenocarcinomas based on epidermal growth factor (EGFR) gene status: a case report. Lung Cancer. 2010;68(3):498-500. [CrossRef]
 
Chang YL, Wu CT, Shih JY, Lee YC. Comparison of p53 and epidermal growth factor receptor gene status between primary tumors and lymph node metastases in non-small cell lung cancers. Ann Surg Oncol. 2011;18(2):543-550. [CrossRef]
 
NOTE:
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.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543