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• W3011965203 abstract "Central MessageA positive bronchial section margin ranges from R uncertain to R1 or R2 involvement with different prognosis.See Article page 267. A positive bronchial section margin ranges from R uncertain to R1 or R2 involvement with different prognosis. See Article page 267. Bronchial sleeve resection is a valid alternative to pneumonectomy on the condition that a complete R0 resection can be obtained, as defined by a working group of the International Association for the Study of Lung Cancer (IASLC) in 2005.1Rami-Porta R. Wittekind C. Goldstraw P. Complete resection in lung cancer surgery: proposed definition.Lung Cancer. 2005; 49: 25-33Abstract Full Text Full Text PDF PubMed Scopus (325) Google Scholar Generally, during the intervention, a frozen section analysis of the bronchial section planes is obtained to document free margins. What is the clinical significance and prognosis of patients with microscopic residual disease at the anastomotic site? Is there a difference between carcinoma in situ and invasive carcinoma? The data in the literature are quite sparse. In the series of Massard and colleagues,2Massard G. Kessler R. Gasser B. Ducrocq X. Elia S. Gouzou S. et al.Local control of disease and survival following bronchoplastic lobectomy for non–small cell lung cancer.Eur J Cardiothorac Surg. 1999; 16: 276-282Crossref PubMed Scopus (32) Google Scholar 7.9% had positive resection margins, and most of these patients died of progressive disease. The authors also reported that carcinoma in situ at a bronchial stump (mutatis mutandis, this also applies to sleeve resections) does not influence survival.3Massard G. Doddoli C. Gasser B. Ducrocq X. Kessler R. Schumacher C. et al.Prognostic implications of a positive bronchial resection margin.Eur J Cardiothorac Surg. 2000; 17: 557-565Crossref PubMed Scopus (53) Google Scholar In the present large and well-described series of 540 patients who underwent sleeve resection between 1995 and 2015, 40 patients (7.4%) had R1 residual disease.4Hong T.H. Kim J. Shin S. Kim H.K. Choi S.Y. Zo J.I. et al.Clinical outcomes of microscopic residual disease after bronchial sleeve resection for non–small cell lung cancer.J Thorac Cardiovasc Surg. 2021; 161: 267-277.e9Abstract Full Text Full Text PDF Scopus (5) Google Scholar Five-year overall survival and recurrence-free survival did not differ between patients with R0 and R1 resection. In addition, the recurrence rate at the bronchial anastomosis did not differ between the groups. Invasive extramucosal involvement was associated with a higher recurrence rate. The general conclusion was that oncologic outcome of microscopic residual disease was not jeopardized. Hong and colleagues are to be commended for providing a detailed evaluation of their patient population and thorough statistical analysis. Nonetheless, this is a retrospective, single-institution study with a limited number of patients with R1 resection, which in itself consists of a heterogenous group ranging from carcinoma in situ at the bronchial anastomosis to frank invasion. Quite interestingly, the authors report that the number of recurrences increased as the location of residual carcinoma changed from the endobronchial side to the outer bronchial wall (Figure 1). Although not statistically significant, overall survival and recurrence-free survival were lower in cases of R1 resection. Generally, in contrast to R2 resection comprising macroscopic residual disease, the significance of R1 involvement has not been firmly established. Moreover, in 2005, the IASLC defined an intermediate category called Run, or uncertain resection, with a prognosis in between that of R0 and R1.1Rami-Porta R. Wittekind C. Goldstraw P. Complete resection in lung cancer surgery: proposed definition.Lung Cancer. 2005; 49: 25-33Abstract Full Text Full Text PDF PubMed Scopus (325) Google Scholar Carcinoma in situ belongs to this category. In a recently published repeat analysis of the IASLC database, the R descriptors were reported to have prognostic relevance, with uncertain resections stratifying between R0 and R1 resections5Edwards J.G. Chansky K. Van Schil P. Nicholson A.G. Boubia S. Brambilla E. et al.The IASLC lung cancer staging project: analysis of resection margin status and proposals for residual tumor descriptors for non-small cell lung cancer.J Thorac Oncol. 2020; 15: 344-359Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar; however, there were only 13 cases with carcinoma in situ at the bronchial margin. Although Hong and colleagues do not explicitly state it, their paper provides additional data to include patients with carcinoma in situ at the bronchial margin in the R uncertain category with a better prognosis than those patients with R1 disease due to microscopic invasive carcinoma at the resection margin. However, still more convincing data are needed to determine the real prognostic significance of R uncertain and to recommend the best adjuvant therapy, especially in the new era of targeted therapies and immunotherapy. Clinical outcomes of microscopic residual disease after bronchial sleeve resection for non–small cell lung cancerThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 1PreviewTo evaluate the significance of microscopic residual disease (MRD) at the bronchial resection margin after bronchial sleeve resection in non–small cell lung cancer. Full-Text PDF" @default.
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• W3011965203 title "Commentary: Positive bronchial section margin: How certain is R uncertain?" @default.
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• W3011965203 doi "https://doi.org/10.1016/j.jtcvs.2020.03.014" @default.
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