Clinical implications of positive margins following non‐small cell lung cancer surgery

Abstract

Positive margins following pulmonary resection of non-small cell lung cancer (NSCLC) occur in approximately 5-15% of patients undergoing a curative procedure. The presence of positive margins negatively impacts long-term outcomes by setting the stage for local and potentially distant disease recurrence. Despite major clinical ramifications, there are very few dedicated reports that examine the implications of positive margins following surgery for NSCLC. Furthermore, published series are typically retrospective studies from single institutions. In this review we analyze published data with special consideration of four pertinent questions: (i) what are the long term outcomes of a positive margin following pulmonary resection?, (ii) is intraoperative margin assessment by frozen section reliable?, (iii) what is the optimal distance of the tumor margin to the surgical margin?, and (iv) should adjuvant chemotherapy and/or radiation therapy be used in the setting of a positive surgical margin?

A Phase I Clinical Trial of Targeted Intraoperative Molecular Imaging for Pulmonary Adenocarcinomas

“…(Ann Thorac Surg 2018;105:901-8) Ó 2018 by The Society of Thoracic Surgeons E ach year, nearly 80,000 patients undergo pulmonary resection for non-small cell lung cancer in the United States [1]. Of those patients, 10% to 17% harbor synchronous or metachronous disease that is unidentified preoperatively [2][3][4].…”

Image‐guided surgery in cancer: A strategy to reduce incidence of positive surgical margins

“…Numerous groups recommend obtaining negative margins for surgical resection of lung cancer, including the International Association for the Study of Lung Cancer (IASLC) (Rami‐Porta, Wittekind, & Goldstraw, ) and the NCCN (National Comprehensive Cancer Network, ). However, compliance with surgical guidelines is poor, as 6–18% of patients undergoing surgery for lung cancer have positive margins, and a further 74% do not undergo sampling of stations, potentially leaving residual disease (Little et al, ; Osarogiagbon et al, ; Predina et al, ; Wakeam et al, ). Patients with PSMs have worse overall survival (OS) by about 50% across all stages (Hancock et al, ; Osarogiagbon et al, ).…”

The importance of R0

“…Incomplete resection for NSCLC is estimated to occur in 5% to 15% of pulmonary resections, and this event is associated with a significant detriment to overall survival of these patients. 2 In general, a variety of biologic (grade/ stage), anatomic (tumor location), physiologic (pulmonary reserve), and technical (pathologic evaluation) factors can be responsible for the occurrence of a positive margin. In an earlier analysis of 5335 positive margins (4.7%) among 112,998 pulmonary resection in the National Cancer Database by the same group, factors associated with incomplete resection included squamous histologic type, high tumor grade, advanced pathologic stage, and tumors overlapping more than a single lobe.…”

“…In the absence of these data, extrapolation of results from studies comparing R0 and R1/2 resections to patients with incompletely resected early-stage NSCLC seems fair, and each of these studies demonstrates improved long-term survival with complete resection. 2,3 Taking these data together with the Author has nothing to disclose with regard to commercial support. In the closing remarks of an editorial recently published in the Journal, Schaheen and D'Cunha 1 highlight the challenge for thoracic surgeons to adequately compare the efficacy of surgical resection and stereotactic body radiation therapy (SBRT) for patients with operable stage I non-small cell lung cancer (NSCLC).…”

“…1 We agree with their comments that ''our patients aren't fully able to dissect the literature and the nuances of the trials'' 1 that have been published in the peer-reviewed literature and then recycled in the lay media with sensationalized headlines. 2 It is for this reason that a multidisciplinary committee of experts across radiation oncology and thoracic surgery recently published the ASTRO (American Society for Radiation Oncology) SBRT evidence-based guideline for early-stage NSCLC and addressed this topic as a key question: ''When is SBRT appropriate for patients with T1-2, N0 NSCLC who are medically operable?'' 3 On the basis of a systematic review of the literature for patients in medically operable condition, our recommendation is that for ''patients with 'standard operative risk' (ie, anticipated operative mortality of <1.5%), lobectomy with systematic mediastinal lymph node evaluation remains the recommended treatment,'' whereas ''discussions about SBRT as a potential alternative to surgery are encouraged'' for patients with higher operative risk.…”