One topic that is rarely considered in the management of SCLC is the role of surgery. The main reason is that the vast majority of patients presenting with SCLC either have extensive disease that has spread throughout the body (2/3 of SCLC presentations) or at least already have rather bulky nodal disease that would make then a less-than-ideal candidate for surgery even if they had NSCLC; the other key component of this bias against surgery is the strong tendency for SCLC to have micrometastatic disease even early in the disease process.

As a conclusion to the string of posts on the topic of lymph nodes removed at the time of surgery, I wanted to touch on the issue of what our representative experience is in the US, because I described the results of specialized centers in Japan and Italy that typically yielded large numbers of lymph nodes, often more than 10.

In the past couple of posts we’ve seen that based on evidence from Japan and Rome, number of lymph nodes resected and also the absolute number of positive nodes and/or proportion of positive nodes may be important prognostic variable. A third abstract I reviewed on the same subject came from Peoria, IL, and illustrated a key reason why using these variables may not be as consistently useful as we’d like, at least in many parts of the world.

In the last post I discussed some interesting work from a group in Japan that suggested that the number of lymph nodes that are removed and positive for NSCLC may be a very important prognostic variable, potentially an even more important factor than location of the nodes, which is the basis for how we stage nodal involvement in NSCLC now.

At this year's ASCO meeting, I had the opportunity to review and provide commentary on several presentations from other researchers, all on the topic of how to refine our ability to predict how patients will do after surgery for stage I - IIIA NSCLC, with an idea that this information can help guide decisions about who should receive chemo and who shouldn't.

I’ve previously described the concept of the “precocious metastasis”, the situation in which a patient presents with early stage NSCLC, except for a single metastasis, most typically in the brain or adrenal gland. Our conventional teaching is that a patient with any metastatic disease almost certainly has additional micrometastatic disease, cancer cells floating in the bloodstream, that will inevitably lead to development of new areas of visible metastatic disease in the future (so having a small amount of metastatic disease would be like being “a little pregnant”).

I was reminded of the important topic of occult N2 NSCLC by a comprehensive review that just came out in the Journal of Thoracic Oncology (abstract here) by a friend, thoracic surgeon Frank Detterbeck, who leads the thoracic oncology program at Yale.

People who have been following my comments know that I am often questioning the wisdom of surgery in patients who don't fit the usual criteria for resection, which is most commonly pursued in stage I and II NSCLC and is often considered an option for some patients with stage IIIA NSCLC. To provide a very quick review of NSCLC staging, it's a combination of three factors:

1) Tumor (T) stage -- from 1 to 4, going from smallest and easiest to remove to hardest or largest to remove

2) Node (N) stage -- from 0 to 3, going from none to further distances from the main tumor

Dr. Laskin has appreciated the warm welcome. Not only have you not scared her off, she's written her first post for us.

By the way, it's misleading to have my name and picture and "about the author" next to these posts by our new faculty -- the software upgrade will fix this. Here's her picture, so you can associate a name with a face (I had threatened to use a Wonder Woman picture if she didn't supply one).

There's a website called Adjuvant! Online, developed by oncologist Peter Ravdin, that is best known for its use after surgery for breast cancer in assessing the value of post-operative chemo. Because I don't really treat breast cancer, I haven't spent time on the website, but I do know that it's a valued resource among practicing oncologists who care for patients with breast cancer.