Winning the Battle, Losing the War: The Noncurative "Curative" Resection for Stage I Adenocarcinoma of the Lung

Background. Understanding recurrence of surgically "cured" stage I adenocarcinoma of the lung is important given expected benefits of adjuvant therapy for advanced disease. Therefore, this study characterizes cancer recurrence and its risks, assesses survival after recurrence, and contextualizes overall survival and its risks. Methods. From 1991 to 2001, 285 patients underwent resection of stage I adenocarcinoma (pathologic) of the lung. They were followed cross-sectionally for evidence of cancer recurrence (mean follow-up 7.7 +/- 4.3 years). Risk factors for recurrence and all-cause mortality were sought among demographic, medical history, cancer pathology, and surgical procedure data. Results. Cancer recurred in 99 patients. Freedom from recurrence was 92%, 72%, and 57% at 1, 5, and 10 years. Two phases of risk were found: an early hazard phase and an essentially constant late phase after 5 years, with recurrences equally distributed. Early recurrence was associated with larger tumor size in patients who did not undergo mediastinal lymphadenectomy (p = 0.004). Late recurrence was more common in patients with higher pack-years of smoking (p = 0.007). Survival after recurrence was 40% and 17% at 1 and 5 years. Overall survival (65% and 40% at 5 and 10 years) depended not only on variables related to cancer recurrence, but also those of vitality (older age, pulmonary dysfunction, postpneumonectomy state). Conclusions. Stage I adenocarcinoma of the lung recurs. Identifying high-risk patients will simplify decision making for adjuvant therapy and surveillance. Thorough mediastinal lymphadenectomy dissociates tumor size as a predictor of survival and may itself provide an important survival benefit. (Ann Thorac Surg 2010;90:1067-74) (c) 2010 by The Society of Thoracic Surgeons