Preface

In this issue of the Thoracic Surgery Clinics, we focus on many points of discussion in present and evolving diagnostic and therapeutic paradigms for stage I non–small cell lung cancer.

We begin with discussions of the role of roentgenographic surveillance of patients at increased risk for development of non–small cell lung cancer. Henschke provides us with compelling arguments for the use of “fast,” low-dose CT screening for middle-aged persons with significant smoking history and some evidence of chronic obstructive pulmonary disease. Her analysis suggests that such screening is cost-effective in detecting and treating lung cancer at an early, curative stage. She compares the effectiveness of such lung cancer surveillance to that of routine mammography in the detection of early-stage breast cancer.

Advances in percutaneous and transbronchial image-guided diagnostics are reviewed by Yankelevitz and Ernst. The emerging role of molecular biologic staging as a means of detecting a higher risk of recurrence among patients with stage I non–small cell lung cancer by the classic TNM staging system is described by Doctor Harpole.

Roth and Luketich give us intriguing insight into the growing enthusiasm for and the potential emerging role of hyperfractionated radiotherapy and radiofrequency ablation techniques for the small peripheral non–small cell lung cancer. Although most thoracic surgeons continue to disqualify these approaches as reasonable frontline therapeutic approaches to resectable non–small cell lung cancer, other competitive medical disciplines are promoting these interventions as both minimally invasive and effective.

The “can do” individualistic spirit of thoracic surgeons is one of our strongest attributes. Thoracic surgeons may choose to ignore these efforts, similar to the tale of the elephant who sticks his trunk under the circus tent. Rather than despair and cry out, “Who is John Galt?” [1], thoracic surgeons can begin to engage themselves in these percutaneous and radiotherapy techniques. Thoracic surgeons should become fully acquainted with these approaches and establish these modalities as another arrow in their quiver for the treatment of stage I non–small cell lung cancer. Neurosurgeons, vascular surgeons, and urologists have faced similar circumstances over the last two decades, and they have positioned themselves to maintain their leadership position in the management of their particular areas of clinical interest. Just as we profess that our surgical approach to esophageal disease should not be governed by the thin muscular slip known as the “diaphragm,” our active, involved approach to curable lung cancer should not be restricted by the presence or absence of a radiation exposure badge.

The utility of sublobar resection for the management of small peripheral non–small cell lung cancers is argued by Pettiford and colleagues. This sublobar resection approach is also described by Yoshida in his appraisal of the management of the peripheral pulmonary “ground glass” opacity. Local recurrence being a primary failure of these sublobar resection approaches has led us to explore the value of adjuvant radiation therapy following sublobar resection. Fernando nicely describes the possible role of intraoperative brachytherapy in reducing this local recurrence event. Maddaus provides us with a contrary point of view in favor of lobectomy for stage I lung cancer, and Rendina gives us insight into the importance of accurate lymph node staging during the course of anatomic lung resection. Rendina also provides further support for the use of mediastinal lymphadenectomy following resection of stage I non–small cell lung cancer.

Thoracoscopic approaches to lobectomy and their merits are described by McKenna and Yim. Walker elaborates on his work in profiling the differences in immunologic suppression between open and thoracoscopic approaches to lobectomy.

The potential role of adjuvant chemotherapy following complete resection of stage I non–small cell cancer is provided by Vallieres. Although medical science, like most other sciences, is “empirical” by nature [2], d'Amato argues that a logical approach to this empiric knowledge be used when suggesting systemic therapy following R0 resection of stage I non–small cell lung cancer.

I invite you to enjoy the contributions of the distinguished and able faculty assembled for this issue. I urge thoracic surgeons to use their individualism, knowledge, energy, and spirit to selfishly strive for improvements in the management paradigms for our patients with curable non–small cell lung cancer.