Editorial
Lung Cancer Surgery in the XXI Century
Tratamiento quirúrgico del cáncer de pulmón en el siglo xxi
José María Matilla-González
Servicio de Cirugía Torácica, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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The incidence of LC among men has begun to fall in countries with the highest Human Development Index (by 0.3% in Spain and 2.5% in the U.S. each year), although rates continue to rise among women (by 1.4% in Australia and 6.1% in Spain).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Patient age and the comorbidity burden (including previous cancers) have also risen progressively. Patients who may benefit from local treatment by surgery using the latest technology can be selected on the basis of individual surgical risk assessment, thus reducing postoperative morbidity and mortality and improving subsequent quality of life.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Histological types still vary between different countries, but there appears to be an increase in adenocarcinoma compared to squamous cell carcinoma, particularly among women.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A multidisciplinary approach and the use of multimodal treatments has helped to increase the chances of achieving local control of the disease and to improve survival in cases in which such an outcome was previously impossible. Overall 5-year survival rates have increased, irrespective of disease stage and treatment.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> The greater presence of adenocarcinomas in more peripheral sites and improvements in diagnosis and oncological treatment have influenced the surgical approach. The number of exploratory thoracotomies and pneumonectomies has fallen progressively, whereas the number of lobectomies and sublobar resections has increased.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Lobectomy with a tumor-free margin and mediastinal lymphadenectomy is associated with better survival and is still the intervention of choice.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> Nevertheless, the best surgical treatment for early-stage LC continues to be controversial. A retrospective analysis of the Surveillance, Epidemiology and End Results (SEER) database on the survival of 15,000 patients who underwent surgery for stage T1a non-small cell LC<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> concluded that lobectomy remains superior to other more conservative resections for all tumors measuring ≥2<span class="elsevierStyleHsp" style=""></span>cm; if sublobar resection is performed, anatomical segmentectomy is preferable when the lesion measures between 1 and 2<span class="elsevierStyleHsp" style=""></span>cm. Despite some limitations such as lack of data on disease recurrence, and the finding that patients with sublobar resection possibly suffer greater comorbidity, this study shows the benefit of more limited resection of small tumors with negative lymph nodes. As regards tumor histology, another retrospective study showed better results for lobectomy in squamous cell carcinomas, while protocolized segmentectomy was equivalent to lobectomy in adenocarcinomas.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The introduction of low-dose CT for screening means that cancers can now be diagnosed at an earlier stage, and due to the increased comorbidity of many patients, borderline candidates for lobectomy may potentially benefit from a more limited resection. However, these factors are still to be determined, and we hope that the ongoing randomized studies, CALBG 140503 and JCOG CALBG082/WJOG4607L comparing lobectomy with sublobar resection will help clarify this issue.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The development of modern, narrow-gauge articulating endoscopic linear cutters, advances in video-assisted thoracoscopy camera technology (including 3D cameras), and the development of more accurate surgical robots have facilitated advances in minimally invasive surgery.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Since the end of the last century, surgeons have been developing surgical interventions in LC using video-assisted thoracoscopy (VATS), with progressively fewer ports, finally arriving at the uniportal VATS technique, which can now be used in increasingly complex cases. VATS surgery has many advantages: less postoperative pain, a shorter hospital stay, reduced inflammatory response, and quicker access to chemotherapy. Another aspect to be considered is robotic surgery. Although still in the early stages, this technique has considerable future potential, and results are similar to those of video-assisted thoracoscopy. However, the use of VATS in advanced disease stages is still rare, and this lack of acceptance is associated with fear of the risk of bleeding or a preference for more radical treatment. The information available on the Internet, the use of live surgical broadcasts during conferences, and courses in experimental surgery have shortened the learning curve and contributed to the development of new surgical procedures in the last decade.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">However, in spite of the innumerable advantages of minimally invasive surgery, the choice of any specific approach should be based on scientific evidence, and radical treatment for the cancer and the best safety conditions must be offered. Minimally invasive surgery as a technique is here to stay, and has changed the attitude of thoracic surgeons towards surgical interventions. But, like all scientific procedures, minimally invasive approaches must find their place within the LC therapeutic arsenal and must undergo scientific scrutiny in terms of long-term survival and follow-up.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Finally, new insights are emerging regarding the role of microRNA and stromal components as potential biomarkers for prognostic stratification and LC classification, and into the use of non-invasive blood biomarkers for early detection which should be of special interest to surgeons. In fact, the study of genetic mutations and their significance as predictors of response to chemotherapy and immunotherapy or as prognostic markers is already an essential feature of new surgical practices.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Over the next few years, then, the professional skills of the thoracic surgeon will expand to include an understanding of biomolecular technology and the adoption of a multidisciplinary approach to the disease, affecting diagnostic, prognostic and therapeutic applications in the treatment of LC.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Matilla-González JM. Tratamiento quirúrgico del cáncer de pulmón en el siglo <span class="elsevierStyleSmallCaps">xxi</span>. Arch Bronconeumol. 2018;54:177–178.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The international epidemiology of lung cancer: latest trends, disparities and tumor characteristics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T.Y. Cheng" 1 => "S.M. Cramb" 2 => "P.D. Baade" 3 => "D.R. Youlden" 4 => "C. Nwogu" 5 => "M.E. 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Boeri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ejcts/ezu048" "Revista" => array:6 [ "tituloSerie" => "Eur J Cardiothorac Surg" "fecha" => "2014" "volumen" => "46" "paginaInicial" => "602" "paginaFinal" => "606" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24623168" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack342738" "titulo" => "Acknowledgement" "texto" => "<p id="par0040" class="elsevierStylePara elsevierViewall">We thank Professor Mariano Garcia Yuste.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005400000004/v2_201804150412/S1579212918300314/v2_201804150412/en/main.assets" "Apartado" => array:4 [ "identificador" => "46447" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005400000004/v2_201804150412/S1579212918300314/v2_201804150412/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212918300314?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 2 | 7 |
| 2024 October | 36 | 21 | 57 |
| 2024 September | 41 | 13 | 54 |
| 2024 August | 61 | 33 | 94 |
| 2024 July | 44 | 28 | 72 |
| 2024 June | 49 | 32 | 81 |
| 2024 May | 65 | 33 | 98 |
| 2024 April | 44 | 23 | 67 |
| 2024 March | 45 | 24 | 69 |
| 2024 February | 40 | 23 | 63 |
| 2023 March | 11 | 3 | 14 |
| 2023 February | 35 | 21 | 56 |
| 2023 January | 28 | 38 | 66 |
| 2022 December | 44 | 40 | 84 |
| 2022 November | 60 | 26 | 86 |
| 2022 October | 49 | 31 | 80 |
| 2022 September | 38 | 32 | 70 |
| 2022 August | 24 | 34 | 58 |
| 2022 July | 37 | 38 | 75 |
| 2022 June | 31 | 32 | 63 |
| 2022 May | 37 | 53 | 90 |
| 2022 April | 31 | 27 | 58 |
| 2022 March | 29 | 30 | 59 |
| 2022 February | 33 | 33 | 66 |
| 2022 January | 40 | 31 | 71 |
| 2021 December | 27 | 44 | 71 |
| 2021 November | 29 | 44 | 73 |
| 2021 October | 40 | 50 | 90 |
| 2021 September | 22 | 45 | 67 |
| 2021 August | 19 | 41 | 60 |
| 2021 July | 21 | 29 | 50 |
| 2021 June | 22 | 36 | 58 |
| 2021 May | 32 | 30 | 62 |
| 2021 April | 39 | 64 | 103 |
| 2021 March | 50 | 24 | 74 |
| 2021 February | 25 | 21 | 46 |
| 2021 January | 25 | 14 | 39 |
| 2020 December | 25 | 14 | 39 |
| 2020 November | 23 | 23 | 46 |
| 2020 October | 31 | 22 | 53 |
| 2020 September | 17 | 11 | 28 |
| 2020 August | 22 | 19 | 41 |
| 2020 July | 32 | 23 | 55 |
| 2020 June | 25 | 11 | 36 |
| 2020 May | 28 | 12 | 40 |
| 2020 April | 57 | 24 | 81 |
| 2020 March | 38 | 11 | 49 |
| 2020 February | 62 | 21 | 83 |
| 2020 January | 60 | 14 | 74 |
| 2019 December | 28 | 17 | 45 |
| 2019 November | 25 | 19 | 44 |
| 2019 October | 14 | 17 | 31 |
| 2019 September | 35 | 17 | 52 |
| 2019 August | 26 | 23 | 49 |
| 2019 July | 17 | 22 | 39 |
| 2019 June | 26 | 15 | 41 |
| 2019 May | 27 | 17 | 44 |
| 2019 April | 24 | 15 | 39 |
| 2019 March | 32 | 13 | 45 |
| 2019 February | 24 | 28 | 52 |
| 2019 January | 40 | 14 | 54 |
| 2018 December | 46 | 21 | 67 |
| 2018 November | 45 | 24 | 69 |
| 2018 October | 46 | 21 | 67 |
| 2018 September | 4 | 0 | 4 |
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