While there is a lot of variability in the clinical behavior of bronchioloalveolar carcinoma (BAC), there are some commonly observed findings that are now leading lung cancer experts to consider it as a distinct clinical entity worthy of special consideration for management. Among the important areas for potentially special clinical management is in surgical management of early stage disease.

I had previously written about a spectrum from pure bronchioloalveolar carcinoma (BAC) to invasive adenocarcinoma in one of my first posts here, but the real credit for this concept goes back to Dr.

Although I’ve described this concept in a few posts over the past year, it’s time for me to dedicate some real discussion to the concept of individualizing treatment with the ERCC1 marker. ERCC1 stands for excision repair cross-complementing group 1, and it helps repair damage to DNA.

The standard of care for at least stage I and II NSCLC is surgery, sometimes followed by chemotherapy. We know, however, that not every patient who presents with early stage NSCLC is healthy enough to pursue surgery, whether due to general age-related or other illnesses, or due specifically to a low pulmonary reserves, usually from years of smoking.

We know PET scans can provide additional metabolic information that can be more sensitive and specific for cancer than chest x-rays and even CT scans in the initial staging of lung cancer (see prior post on introduction to PET scans). PET scans are now nearly universally employed in the initial workup, at least of patients who have NSCLC and aren’t already known to have stage IV disease.

Among the key issues in following patients with a history of treated lung cancer is the pattern of recurrence. We need to have a sense of when the risk is highest and where people are more likely to demonstrate new evidence of disease. Fortunately, there are several studies that can help us with these questions.

Throughout multiple discussions of adjuvant chemotherapy, I've focused on the traditional approach used in the US and Europe of 3-4 cycles of platinum-based chemo, treating for up to about three months with a rather intensive approach. However, in Japan, they've studied the value of a different form of adjuvant treatment, with a drug called UFT that is generally well-tolerated, mild, and taken for 1-2 years by mouth.

Among the many variables that can potentially be helpful in predicting outcomes after surgery are some imaging results. One of these is cavitation, or hollowing out of the inside of some part of the tumor. Although most clinicians think of this as a feature of squamous cancers, it can also be seen with adenocarcinomas and other histologies less frequently.

The decision about pursuing post-operative treatment is often difficult and requires carefully weighing the risks of treatment with potentially challenging and even dangerous chemotherapy against the potential to eradicate micrometastases and actually lead some people to be cured who otherwise wouldn't be. It's important to remember that some people are already cured, while others won't be cured even with treatment.

While there are good reasons to not pursue chemo after surgery for stage I NSCLC, there are several factors that argue at least for strong consideration of adjuvant chemotherapy for higher risk patients. Because stage IB generally has a less favorable prognosis than stage IA, it's not suprising that the debate about which patients should or should not be receiving post-op chemo has centered more on the stage IB population, which have much more commonly been included in trials testing the value of adjuvant chemotherapy.