A novel test of the surgical margin in patients with lung cancer undergoing limited surgery: lavage cytologic technique

Stapler-lavage cytology using a new rapid immunocytochemistry for evaluating surgical margin status after pulmonary sublobar resection

OBJECTIVE

Sublobar resection is considered the gold standard for selected patients with pulmonary metastasis or who are compromised in some way. However, an unfavorable outcome after sublobar resection is local/margin recurrence. The aim of this study was to evaluate the clinical reliability of a new rapid-stapler lavage immunocytochemistry (ICC) technique for assessing margin malignancy. The method uses non-contact alternating current (AC) mixing to achieve more stable staining.

METHODS

Twenty-one patients who underwent sublobar resection, including 16 wedge resections, for pulmonary metastasis or lung cancer in a compromised host between September 2016 and December 2017 were retrospectively reviewed. All margin specimens were intraoperatively evaluated with HE staining of frozen sections and stapler lavage cytology using Papanicolaou staining and rapid-ICC.

RESULTS

Rapid-stapler lavage ICC can be used to diagnose surgically safe margins within 20 min during sublobar resections. Although in all cases margins were diagnosed as cancer free based on HE staining of frozen sections, two of four patients diagnosed with malignant-positive margins based on rapid ICC experienced local/margin recurrence.

CONCLUSIONS

Rapid-stapler lavage ICC with AC mixing could potentially serve as a clinical tool for prompt determination of margin malignant status after pulmonary sublobar resection.

Delayed cut-end recurrence after wedge resection for pulmonary ground-glass opacity adenocarcinoma despite negative surgical margin

Most pulmonary ground-glass opacity (GGO) nodules are pathologically well differentiated adenocarcinomas. We performed a limited resection trial of GGO lesions 2 cm or smaller from 2003 to 2009, in which 95 patients were accumulated. We confirmed negative surgical cut-end during surgery by margin lavage cytology. In the trial, a 51-year-old man underwent right lower lobe wedge resection for a 1.7 cm mixed GGO lesion. The tumor was papillary predominant adenocarcinoma, pT1NxM0. The resection scar became thicker and was diagnosed as adenocarcinoma by needle biopsy 10 years after the initial surgery. We performed a right lower lobectomy and lymph node dissection. Pathologically, the second tumor was adenocarcinoma similar to the initial one, papillary predominant, and was diagnosed as cut-end recurrence. Small papillary predominant adenocarcinoma might develop delayed cut-end recurrence more than 5 years after limited resection. Careful follow-up with special attention to the cut-end is necessary ideally for 10 years.

Management of the Peripheral Small Ground-Glass Opacities

Pure ground-glass opacities (GGO) with a small consolidation area are mostly bronchioloalveolar carcinomas that have not yet become invasive, whereas a minority represents only inflammatory changes. Even if they are cancers, they are slow-growing and often remain unchanged for several years. There is no need for immediate resection of GGO lesions and a watchful waiting strategy is recommended. It seems that a lower-impact surgery (eg, wedge resection or segmentectomy) is curative for these lung cancers. Because high-resolution CT seems to predict noninvasive or minimally invasive GGO lung cancers with high reliability, less invasive treatments like radiofrequency ablation have greater appeal.

Predictive factors for local recurrence of resected colorectal lung metastases

BACKGROUND

Wedge resection or segmentectomy are the preferred treatments for pulmonary metastasis from colorectal cancer. However, local recurrence at the surgical margin is a problem with limited resections. This study attempted to identify predictive factors associated with local recurrences at the surgical margin after resection of pulmonary metastases.

METHODS

A total of 96 lesions in 61 patients who had undergone a pulmonary wedge resection or segmentectomy for the treatment of pulmonary metastasis from colorectal cancer were investigated. Various clinical and pathologic factors were reviewed, and the risk of a local recurrence at the surgical margin was investigated.

RESULTS

After pulmonary resection, 34 of the 61 patients (56%) experienced recurrences in their lungs. Local recurrences at the surgical margin were found in 17 patients (28%), even though 15 of these 17 cases had been histologically confirmed as completely resected cases. No clinical factors associated with local recurrence at the surgical margin were identified. Pathologically, lesions exhibiting 10 or more aerogenous spreads with floating cancer cell clusters around the main tumor (p = 0.02) and a malignant positive surgical margin (p = 0.04) had a significantly higher risk of local recurrence.

CONCLUSIONS

The present study indicated that local recurrence may occur even in cases with a pathologically negative surgical margin. In cases with pulmonary metastases from colorectal cancer, lesions with 10 or more aerogenous spreads with floating cancer cell clusters around the main lesion and a malignant positive surgical margin in the resected specimens have a significantly higher risk of local recurrence at the surgical margin than those without.

Optimal distance of malignant negative margin in excision of nonsmall cell lung cancer: a multicenter prospective study

BACKGROUND

Complete excision of nonsmall cell lung cancer is necessary during a limited resection procedure, as a malignant positive margin can lead to margin relapse. Because there is scant information available regarding the optimal size of a malignant negative margin, we conducted a multicenter, prospective study to more fully elucidate this area of concern.

METHODS

Two hundred five pulmonary tumors (22 nonsmall cell lung cancers and 183 undiagnosed lesions) were excised, of which 118 nonsmall cell lung cancer lesions were analyzed. Malignant status was considered positive when either a cytologic or histologic technique revealed the margin to be malignant. Maximum tumor diameter (from 4 to 45 mm with an average of 15.3 mm), margin distance (from 0 to 25 mm with an average of 9.3 mm), tumor location, extent of stapling carried out, and performance of a thoracotomy were the variables.

RESULTS

Seventy-two of the sample tissues (61%) were malignant negative. The negative group had smaller maximum tumor diameter, greater margin distance, lesions in more easily resectable regions, and more often required stapling only. Using a multivariate analysis, maximum tumor diameter and margin distance were found to be independent factors. The number of malignant negative margins was 7/7 (100%) when the margin distance was greater than 20 mm, and the number of malignant negative margins was 21 of 21 (100%) when the resected tumors had a margin distance greater than the maximum tumor diameter.

CONCLUSIONS

Malignant positive margins were not found when the margin distance was greater than the maximum tumor diameter, which was considered to be the optimal margin distance for prevention against margin relapse.

Intraoperative lavage cytologic analysis of surgical margins in patients undergoing limited surgery for lung cancer

BACKGROUND

One of the unfavorable recurrent patterns after limited surgery for lung cancer is local failure, especially at the surgical margin in the pulmonary parenchyma. To prevent this failure, we preliminarily introduced a novel intraoperative lavage cytologic technique to check surgical margin status for limited surgery. In this study we analyzed the clinical utility of this technique with a larger number of patients under long-term follow-up.

METHODS

A total 112 consecutive lung cancer lesions prospectively treated by limited surgery with the intraoperative lavage cytologic technique between October 1997 and August 2000 were reviewed through a median follow-up period of 27 months.

RESULTS

Eleven lesions (10%) showed cytologically positive results in the attempted surgery on the surgical margin. The positive result rate was significantly higher for lesions with more advanced stage, compromised indication, incurability, and larger size. Surgical modes were converted intraoperatively for 4 lesions; in the other 7 lesions no conversion was performed because of certain disadvantages. Local recurrence in the surgical margin occurred in a total of 4 lesions, including 3 for which the operative mode was unconverted and 1 lesion with cytologically unknown status of the surgical margin that had the mode converted, whereas there were no local recurrences in the surgical margins among the lesions with final cytologically negative results.

CONCLUSION

Cytologically negative results of examination of the surgical margin by the technique of intraoperative lavage cytologic in limited surgery for lung cancer may be predict lack of local recurrence in the surgical margin. This intraoperative cytologic technique is clinically useful in checking for complete resection of this primary disease.

Cytologically malignant margins of wedge resected stage I non-small cell lung cancer

BACKGROUND

We have developed a novel test for the surgical margin of pulmonary malignant tumor using a cytologic technique (the run-across method in which a glass slide is run across the staple site), and we have assessed whether this method is useful in predicting margin relapse and prognosis.

METHODS

From April 1996 to March 1999, 15 lesions of stage I non-small cell lung cancer (NSCLC) (maximum diameter ranged from 10 to 35 mm with a median of 20 mm) from 15 patients with cardiopulmonary impairment were excised without additional proximal resections. The surgical margin was examined using the run-across method. There were 8 male 7 female patients whose ages ranged from 51 to 80 years. One patient underwent video-assisted thoracic surgery and 14 underwent thoracotomy. The preoperative diagnoses of the patients were 13 adenocarcinomas, 2 squamous cell carcinomas, and 1 undiagnosed lesion (1 adenocarcinoma). The follow-up period ranged from 37 to 63 months.

RESULTS

The rate of positive cytology was 47% in comparison with the rate of positive histology of 20%. There were 4 patients with margin relapse (3 of them contained negative histology margins) at a rate of 57% among the positive cytology patients in comparison with 0% among the negative cytology patients (p = 0.03). In a comparison of survival between the negative cytology group and the positive cytology group, there were no statistically significant differences.

CONCLUSIONS

The run-across method is also useful in confirming complete resection. A positive cytology margin could lead to margin relapse even if a non-small cell lung cancer is resected with a negative histology margin.

Natural history of pure ground-glass opacity after long-term follow-up of more than 2 years

BACKGROUND

Pure ground-glass opacity (PGGO) is a new entity that has been clearly defined on high-resolution computed tomography (CT) during the last half decade. It is important to investigate the natural history of PGGO through long-term observation for the management of this new entity.

METHODS

We investigated 19 patients with PGGO(s) defined on high-resolution computed tomography and retained as PGGO for more than 2 years. The PGGOs of 11 patients were detected at annual mass screening by low-radiation-dose CT (low-dose CT), 7 at follow-up CT after cancer resection, and 1 incidentally on CT. After long-term observation, 10 of 19 patients underwent operation and 9 are currently being followed-up with CT. Their growth characteristics and histologic findings are reported.

RESULTS

The median follow-up period was 32 months, ranging from 24 to 124 months. The sizes of PGGOs at the time of discovery were 4 to 18 mm in largest diameter (average 8.6 mm). During follow-up, the size of PGGO showed no change in 8 patients, increased slightly (up to 5 mm) in 6 patients, and increased by more than 5 mm in 5 patients. Ten patients had limited resection (segmentectomy or wide wedge resection) with negative surgical margin by intraoperative lavage cytology of the resection margin of the lung. Of them, 5 patients had adenocarcinoma, 3 pulmonary lymphoproliferative disorder, and 1 each atypical adenomatous hyperplasia and focal fibrosis. There was no clear tendency between the degree of size change and histology. In all but 1 of 9 patients with follow-up only, the PGGOs showed either no change or only a slight increase within 5 mm in largest diameter.

CONCLUSIONS

These data suggest that some PGGOs will never progress to clinical disease and would be included in the category of overdiagnosis bias. However, a prior history of lung cancer should significantly raise the index of suspicion, as 4 of 5 proven cancer cases in this small series fell into that category. Because of the difficulties of preoperative and intraoperative histodiagnosis of PGGO, minimally invasive surgery may be appropriate from the viewpoints of both diagnosis and curability.

Transmediastinal approach to exploring the lung contralateral to the thoracotomy site

OBJECTIVE

The approach to contralateral lung through the mediastinum is assumed useful in managing oddly distributed bilateral lung tumors.

SUBJECTS AND METHODS

To remove a tumor located in the contralateral lung, a transmediastinal approach from the thoracotomy site to the contralateral lung was used in 6 patients having oddly distributed bilateral lung tumors, 1 of which was located in the contralateral lung close to the anterior or posterior mediastinum.

RESULTS

All cases were treated successfully. One patient required an additional small incision on the contralateral anterior chest wall to insert an endoscopic stapler without intraoperative postural change. The postoperative course was uneventful and, to date, no local recurrence has been seen at the resected margin of the contralateral lung.

CONCLUSION

This novel approach is useful, offering the advantages of reduced invasiveness and pain, shorter surgical duration, and favorable cosmetic results for patients with a tumor close to the mediastinum in the contralateral lung.