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Dr West

How Long A Period of Follow-Up is Long Enough to Be Confident a Ground Glass Opacity Won’t Grow?

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GGO over timeAn interesting article from Japan was published out in the Journal of Thoracic Oncology that asks how long a duration of follow-up imaging of a ground-glass opacity (GGO) is really needed to be confident it’s going to remain stable and not grow.   It’s very common to see small lung nodules that are ambiguous in their significance, for which follow-up scans are typically recommended rather than diving into a biopsy, and non-solid, hazy GGOs are another form of lung lesion that might possibly represent a lung cancer but are also the way a little inflammation or small infection would appear.   Even when they turn out to be something technically called cancer based on its appearance under the microscope, it’s often a non-invasive adenocarcinoma (sometimes termed bronchioloalveolar carcinoma, or BAC, but shifting in terminology to adenocarcinoma in situ, or AIS) or minimally invasive adenocarcinoma (MIA), in which the invasive component is less than 5 mm in diameter.  Even when they grow, it can be at an extremely slow pace.

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Dr West

Revisiting the Optimal Early Stage NSCLC Patients for Sublobar Resection

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A very recent issue of the Journal of Thoracic Oncology, the official journal of the International Association for the Study of Lung Cancer, featured a very good review article by the surgical group at NYU about increasing interest in the concept of whether sublobar resection may be comparably effective as a lobectomy for some patients with early stage NSCLC; this article was also accompanied by a thoughtful editorial by expert thoracic surgeon Frank Detterbeck at Yale. (A review of the different types of lung cancer surgery is available through my prior post, and also a great podcast with thoracic surgeon Dr. Eric Vallières).

The excellent review article starts with the background that the general premise that thoracic surgery has been dominated by the results of a pivotal randomized study published in 1995 by the now-defunct Lung Cancer Study Group that showed that sub-lobectomy in early stage NSCLC patients was associated with a higher risk for loco-regional recurrence, a lower survival at 5 years out, and no significant improvement in lung function compared with lobectomy. However, we can be thankful that there have been many advances in management of lung cancer over the past 15-20 years since the trial was actually conducted. First, squamous cell carcinoma was the dominant histologic subtype of NSCLC at that time, whereas now there is more adenocarcinoma and bronchioloalveolar carcinoma than we used to see. Second, it’s now possible to do many lung surgeries with video-assisted thoracoscopic surgery (VATS) that make it possible to do a safer and less rigorous surgery (either lobectomy or sub-lobectomy). Third, with CT scans getting so much better over time, we’re now regularly detecting many more tiny nodules than ever before. The lung cancers detected based on symptoms in 1991 are different from the asymptomatic lung cancers that may well be detected increasingly by CT screening in 2011. Do we really want to remove 1/5 of the lung capacity for an 8 mm nodule? Because we’re using data from much larger and different cancers when we decide to do that.

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Dr West

Watching Small Lung Lesions Do Nothing: “Ground Glass Opacities” Don’t Progress Over Years If They’re Watched, Not Resected

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In one of my earliest posts about bronchioloalveolar carcinoma (BAC) (in the dark ages, pre-Twitter), I wrote on the subject of managing small BAC-type lesions, which tend to appear as small hazy areas called “ground glass opacities” (GGOs) and suggested that some of these cancers may be so indolent that they don’t need to be treated, even if they have the word “carcinoma” in the diagnosis.

ggo (a representative GGO identified by arrow)

Now there is a proposal to change BAC to “adenocarcinoma in situ“, a pre-cancerous condition, reflecting the idea that these lesions have such a favorable prognosis that they shouldn’t necessarily be put in the same category as invasive lung cancers (pure BAC is a non-invasive lesion that shouldn’t be able to get into the bloodstream and spread outside of the lungs). And now, there’s a new article out of Japan that describes the experience of patients with BAC and multiple GGOs, some of which were resected and some not very accessible and some just watched. It turned out that just watching seemed to be a pretty good strategy.

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