- Email: [email protected]
Is Pneumonectomy Justified in Patients With Locally Advanced NSCLC and Persistent N2 Disease After Induction Chemotherapy?
990
CORRESPONDENCE
We should not pursue a procedure that is applied to limited stages only; rather, we should use a standardized approach that can be applied to a broad range of stages. We consider it very important to maintain the quality of the operation and to minimize the destruction and deformity of the thoracic wall. There is no need to focus on whether the procedure is complete or assisted with the VATS approach. This depends on the surgeon’s preference and it is immaterial for the patient to determine the complete or VATS approach.
Ann Thorac Surg 2009;87:985–92
that patients operated on by a totally endoscopic technique have less blood loss, shorter hospitalization, and faster recovery with similar survival [4]. With the development of VATS lobectomies for lung cancer, whatever the names and technical variations may be, we are facing a debate that occurred 10 years ago in laparoscopy and that is now partly solved. I would thus suggest observing various techniques without prejudice, studying their benefits and limitations, and let time and trials make way for the sorting.
Mitsuhiro Kamiyoshihara, MD, PhD Takashi Ibe, MD
Dominique Gossot, MD
Department of General Thoracic Surgery Maebashi Red Cross Hospital 3-21-36 Asahi-Cho Maebashi, Gunma 371-0014, Japan e-mail: [email protected]
Thoracic Department Institut Mutualiste Montsouris 42, Boulevard Jourdan Paris, F-75014 France e-mail: [email protected]
References
References
1. Gossot D. Technical tricks to facilitate totally endoscopic major pulmonary resections. Ann Thorac Surg 2008;86:323– 6. 2. Okada M, Sakamoto T, Yuki T, Mimura T, Miyoshi K, Tsubota N. Hybrid surgical approach of video-assisted minithoracotomy for lung cancer. Significance of direct visualization on quality of surgery. Chest 2000;128:2696 –701.
1. Kamiyoshihara M, Ibe T. The blurred border between thoracoscopic surgery and thoracotomy (letter). Ann Thorac Surg 2009;87:989 –90. 2. Gossot D. Technical tricks to facilitate totally endoscopic major pulmonary resections. Ann Thorac Surg 2008;86:323– 6. 3. Jones RO, Casali G, Walker WS. Does failed video-assisted lobectomy for lung cancer prejudice immediate and longterm outcome? Ann Thorac Surg 2008;86:235–9. 4. Shigemura N, Akashi A, Funaki S, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multiinstitutional study. J Thorac Cardiovasc Surg 2006;132:507–12.
Reply To the Editor: The criticism from Drs Kamiyoshihara and Ibe [1] on my article [2] is based on a prejudice, that is, that totally endoscopic or complete video-assisted thoracoscopic surgical lobectomies are not equal to conventional video-assisted thoracoscopic surgery (VATS) or open lobectomies. I suggest that the authors consider another hypothesis: In some indications, could a complete VATS be equivalent or even superior? This is a question we still cannot answer, but we should at least stay open minded, considering the fact that the history of VATS lobectomies is both recent and multiform. I wish to answer some of these doctors’ remarks as follows:
MISCELLANEOUS
1. “What if nodes are identified as positive during or after the operation?” In which way is this issue different during an open procedure? Our indications are limited to clinical N0 cancers so far. We perform a radical lymphadenectomy, which is as satisfactory as those done by a mini-incision, whose location rarely fits all lymph node stations. Some of our patients are then upstaged to pN1 or even pN2, as they would also be after an open approach. If a nondissectable lymph node were encountered, a thoracotomy could be performed, and as recently shown in this journal by Jones and colleagues [3], a conversion does not impact the outcome of these patients. 2. “We should not pursue a procedure that is applied to limited stage only.” Why should we stay stuck to not using a unique approach? Digestive surgeons find it natural to use a laparoscopic approach for limited stage cancer and a laparotomy for advanced or complex cases. It seems better both for patients and for surgeons to master a wider range of techniques. 3. “There is no need to focus on whether the procedure is complete or assisted VATS.” Again, this is an assertion that is not grounded on evidence. Based on our limited experience of 120 patients, we certainly can not assert that our technique is superior to another one, but there are some indications © 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
Is Pneumonectomy Justified in Patients With Locally Advanced NSCLC and Persistent N2 Disease After Induction Chemotherapy? To the Editor: With some concern we read the article by Mansour and colleagues [1] in the July 2008 issue of The Annals of Thoracic Surgery on the outcome in patients with nonsmall cell lung cancer (NSCLC) and N2 disease after pneumonectomy. They discuss the question of whether it is reasonable to subject a patient to this high-risk procedure with postoperative (⬍ 90 day) mortality of 10% after induction therapy. Their conclusion is in favor of aggressive surgical management (ie, perform pneumonectomy in patients with or without downstaging after induction therapy), as long-term survival in their series was satisfactory. Unfortunately, there seems to be something wrong with the presented survival analysis. The study included patients between January 1999 and July 2005. The last date of follow-up was January 1, 2007. From 36 months to 84 months of follow-up, the presented numbers of patients at risk are the same, although the censoring marks of the survival curves suggest otherwise. Also, it seems unlikely that the majority of patients were treated before the year 2000, as only these patients could be followed for 84 months. A 5-year disease-free survival rate of 43.3% was reported for the group of patients who underwent pneumonectomy after induction chemotherapy, and had persistent N2 disease, whereas the 5-year overall survival rate was reported to be 32.2%. This is impossible, as the proportion of disease-free patients can not be higher than the proportion of patients alive. We tend to disagree with the conclusion of the authors that pneumonectomy is justified in patients with persistent N2 disease 0003-4975/09/$36.00
Ann Thorac Surg 2009;87:985–92
Houke M. Klomp, MD Ingrid Kappers, MD Department of Surgery The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital Plesmanlaan 121 Amsterdam, 1066 CX Netherlands e-mail: [email protected]
References 1. Mansour Z, Kochetkova EA, Santelmo N, et al. Persistent N2 disease after induction therapy does not jeopardize early and medium term outcomes of pneumonectomy. Ann Thorac Surg 2008;86:228 –33. 2. Thomas M, Rube C, Hoffknecht P, et al. Effect of preoperative chemoradiation in addition to preoperative chemotherapy: a randomised trial in stage III non-small-cell lung cancer. Lancet Oncol 2008;9:636 – 48.
Should Thoracoscopic Surgery Be the Standard Management for Patients With Primary Pneumothorax? To the Editor: I read the article by Chen and colleagues [1] with great interest and I must say it is well designed and informative, although I think three main points should be addressed. First, although video-assisted thoracic surgery pleurectomy may be an acceptable option after the first episode of pneumothorax, I would not consider this standardized as the first line of management. The majority of these patients can be successfully treated with a small-bore intercostal drain, which carries minimal morbidity. Chee and colleagues [2] showed that 100% of primary pneumothoraxes with persistent air leaks for more than 7 days treated by tube drainage had resolved their air leaks by 14 days. Furthermore, 79% of those with secondary pneumothoraxes and persistent air leaks had resolved their air leaks by 14 days with no mortality. Second, I also wondered when the author believed that the air leak prolonged and justified a video-assisted thoracic surgery pleurectomy. This interval is not clearly mentioned in the article. Finally, I wonder whether the cost between a video-assisted thoracic surgery procedure and the insertion of an intercostal drain is statistically significant. Clearly in high-volume hospitals, treatment costs for primary spontaneous pneumothorax can represent a significant financial burden. Hany Elsayed, MRCS The Cardiothoracic Centre Liverpool 4 Isleham Close Liverpool, L19 4XS United Kingdom e-mail: [email protected]
991
2. Chee CB, Abishaganaden J, Yeo JK, et al. Persistent air-leak in spontaneous pneumothorax— clinical course and outcome. Respir Med 1998;92:757– 61.
Reply To the Editor: We appreciate very much the interest expressed by Dr Elsayed [1] regarding our article on the salvage for unsuccessful aspiration of primary spontaneous pneumothorax [2]. Elsayed [1] raised an important controversy in the management of the first episode of spontaneous pneumothorax. We agree that videoassisted thoracic surgery (VATS) should not be the standard first line of management. In the current practice, both simple aspiration and chest tube drainage (CTD) are acceptable first line managements in patients requiring intervention. In our hospital, we prefer simple aspiration because it is as effective as CTD with reduced morbidity, hospital stay, and the need for hospitalization [3]. Using VATS is usually reserved for patients with recurrence or persistent air leakage. The definition of “persistent” air leakage after CTD is arguable, because almost all primary pneumothoraxes resolve spontaneously within 14 days. To prevent prolonged hospitalization, the American College of Chest Physicians (ACCP) recommends continued observation for 5 days before encouraging the patient to accept a surgical intervention [4]. Several authors, including us, have recommended operative intervention as early as 3 days for a persistent air leak [5]. The definition and management of persistent air leakage after simple aspiration is more contentious. In the guidelines published by the British Thoracic Society, CTD is recommended if repeat aspiration is unsuccessful, without providing any evidence [6]. If we accept that simple aspiration is equally effective as CTD in managing primary spontaneous pneumothorax, why should we choose CTD as the salvage procedure after unsuccessful aspiration? We hypothesize that patients with unsuccessful aspiration represent highly selected individuals with a higher failure rate of treatment even if a chest tube has been placed, and a more effective procedure such as VATS should be considered. In our CTD patients, we perform VATS if air leaks are greater than 72 hours. We agree that VATS costs more medical expenditure when compared with CTD alone. However, if these young, active patients can go back to work or school earlier without fear of prolonged air leakage and recurrence, maybe more social resources can be saved. A prospective, randomized study is recommended to answer the controversy regarding the optimal treatment for patients with unsuccessful simple aspiration. Jin-Shing Chen, MD, PhD Yung-Chie Lee, MD, PhD Department of Surgery National Taiwan University Hospital and National Taiwan University College of Medicine Departments of Surgery and Traumatology No. 7, Chung-Shan South Rd Taipei, 100 Taiwan e-mail: [email protected]
References References 1. Chen JS, Hsu HH, Tsai KT, Yuan A, Chen WJ, Lee YC. Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage? Ann Thorac Surg 2008;85:1908 –13. © 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Elsayed HH. Should thoracoscopic surgery be the standard management for patients with primary pneumothorax? (letter) Ann Thorac Surg 2009;87:991. 2. Chen JS, Hsu HH, Tsai KT, Yuan A, Chen WJ, Lee YC. Salvage for unsuccessful aspiration of primary pneumothorax: thora0003-4975/09/$36.00
MISCELLANEOUS
after induction chemotherapy. In the light of this discussion, the recently reported data by the German Lung Cancer Cooperative Group are interesting, as they reported a 5-year disease-free survival of 12% in patients with complete resection (ie, lobectomy or pneumonectomy) and persistent N2 disease [2].
CORRESPONDENCE
CORRESPONDENCE
We should not pursue a procedure that is applied to limited stages only; rather, we should use a standardized approach that can be applied to a broad range of stages. We consider it very important to maintain the quality of the operation and to minimize the destruction and deformity of the thoracic wall. There is no need to focus on whether the procedure is complete or assisted with the VATS approach. This depends on the surgeon’s preference and it is immaterial for the patient to determine the complete or VATS approach.
Ann Thorac Surg 2009;87:985–92
that patients operated on by a totally endoscopic technique have less blood loss, shorter hospitalization, and faster recovery with similar survival [4]. With the development of VATS lobectomies for lung cancer, whatever the names and technical variations may be, we are facing a debate that occurred 10 years ago in laparoscopy and that is now partly solved. I would thus suggest observing various techniques without prejudice, studying their benefits and limitations, and let time and trials make way for the sorting.
Mitsuhiro Kamiyoshihara, MD, PhD Takashi Ibe, MD
Dominique Gossot, MD
Department of General Thoracic Surgery Maebashi Red Cross Hospital 3-21-36 Asahi-Cho Maebashi, Gunma 371-0014, Japan e-mail: [email protected]
Thoracic Department Institut Mutualiste Montsouris 42, Boulevard Jourdan Paris, F-75014 France e-mail: [email protected]
References
References
1. Gossot D. Technical tricks to facilitate totally endoscopic major pulmonary resections. Ann Thorac Surg 2008;86:323– 6. 2. Okada M, Sakamoto T, Yuki T, Mimura T, Miyoshi K, Tsubota N. Hybrid surgical approach of video-assisted minithoracotomy for lung cancer. Significance of direct visualization on quality of surgery. Chest 2000;128:2696 –701.
1. Kamiyoshihara M, Ibe T. The blurred border between thoracoscopic surgery and thoracotomy (letter). Ann Thorac Surg 2009;87:989 –90. 2. Gossot D. Technical tricks to facilitate totally endoscopic major pulmonary resections. Ann Thorac Surg 2008;86:323– 6. 3. Jones RO, Casali G, Walker WS. Does failed video-assisted lobectomy for lung cancer prejudice immediate and longterm outcome? Ann Thorac Surg 2008;86:235–9. 4. Shigemura N, Akashi A, Funaki S, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multiinstitutional study. J Thorac Cardiovasc Surg 2006;132:507–12.
Reply To the Editor: The criticism from Drs Kamiyoshihara and Ibe [1] on my article [2] is based on a prejudice, that is, that totally endoscopic or complete video-assisted thoracoscopic surgical lobectomies are not equal to conventional video-assisted thoracoscopic surgery (VATS) or open lobectomies. I suggest that the authors consider another hypothesis: In some indications, could a complete VATS be equivalent or even superior? This is a question we still cannot answer, but we should at least stay open minded, considering the fact that the history of VATS lobectomies is both recent and multiform. I wish to answer some of these doctors’ remarks as follows:
MISCELLANEOUS
1. “What if nodes are identified as positive during or after the operation?” In which way is this issue different during an open procedure? Our indications are limited to clinical N0 cancers so far. We perform a radical lymphadenectomy, which is as satisfactory as those done by a mini-incision, whose location rarely fits all lymph node stations. Some of our patients are then upstaged to pN1 or even pN2, as they would also be after an open approach. If a nondissectable lymph node were encountered, a thoracotomy could be performed, and as recently shown in this journal by Jones and colleagues [3], a conversion does not impact the outcome of these patients. 2. “We should not pursue a procedure that is applied to limited stage only.” Why should we stay stuck to not using a unique approach? Digestive surgeons find it natural to use a laparoscopic approach for limited stage cancer and a laparotomy for advanced or complex cases. It seems better both for patients and for surgeons to master a wider range of techniques. 3. “There is no need to focus on whether the procedure is complete or assisted VATS.” Again, this is an assertion that is not grounded on evidence. Based on our limited experience of 120 patients, we certainly can not assert that our technique is superior to another one, but there are some indications © 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
Is Pneumonectomy Justified in Patients With Locally Advanced NSCLC and Persistent N2 Disease After Induction Chemotherapy? To the Editor: With some concern we read the article by Mansour and colleagues [1] in the July 2008 issue of The Annals of Thoracic Surgery on the outcome in patients with nonsmall cell lung cancer (NSCLC) and N2 disease after pneumonectomy. They discuss the question of whether it is reasonable to subject a patient to this high-risk procedure with postoperative (⬍ 90 day) mortality of 10% after induction therapy. Their conclusion is in favor of aggressive surgical management (ie, perform pneumonectomy in patients with or without downstaging after induction therapy), as long-term survival in their series was satisfactory. Unfortunately, there seems to be something wrong with the presented survival analysis. The study included patients between January 1999 and July 2005. The last date of follow-up was January 1, 2007. From 36 months to 84 months of follow-up, the presented numbers of patients at risk are the same, although the censoring marks of the survival curves suggest otherwise. Also, it seems unlikely that the majority of patients were treated before the year 2000, as only these patients could be followed for 84 months. A 5-year disease-free survival rate of 43.3% was reported for the group of patients who underwent pneumonectomy after induction chemotherapy, and had persistent N2 disease, whereas the 5-year overall survival rate was reported to be 32.2%. This is impossible, as the proportion of disease-free patients can not be higher than the proportion of patients alive. We tend to disagree with the conclusion of the authors that pneumonectomy is justified in patients with persistent N2 disease 0003-4975/09/$36.00
Ann Thorac Surg 2009;87:985–92
Houke M. Klomp, MD Ingrid Kappers, MD Department of Surgery The Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital Plesmanlaan 121 Amsterdam, 1066 CX Netherlands e-mail: [email protected]
References 1. Mansour Z, Kochetkova EA, Santelmo N, et al. Persistent N2 disease after induction therapy does not jeopardize early and medium term outcomes of pneumonectomy. Ann Thorac Surg 2008;86:228 –33. 2. Thomas M, Rube C, Hoffknecht P, et al. Effect of preoperative chemoradiation in addition to preoperative chemotherapy: a randomised trial in stage III non-small-cell lung cancer. Lancet Oncol 2008;9:636 – 48.
Should Thoracoscopic Surgery Be the Standard Management for Patients With Primary Pneumothorax? To the Editor: I read the article by Chen and colleagues [1] with great interest and I must say it is well designed and informative, although I think three main points should be addressed. First, although video-assisted thoracic surgery pleurectomy may be an acceptable option after the first episode of pneumothorax, I would not consider this standardized as the first line of management. The majority of these patients can be successfully treated with a small-bore intercostal drain, which carries minimal morbidity. Chee and colleagues [2] showed that 100% of primary pneumothoraxes with persistent air leaks for more than 7 days treated by tube drainage had resolved their air leaks by 14 days. Furthermore, 79% of those with secondary pneumothoraxes and persistent air leaks had resolved their air leaks by 14 days with no mortality. Second, I also wondered when the author believed that the air leak prolonged and justified a video-assisted thoracic surgery pleurectomy. This interval is not clearly mentioned in the article. Finally, I wonder whether the cost between a video-assisted thoracic surgery procedure and the insertion of an intercostal drain is statistically significant. Clearly in high-volume hospitals, treatment costs for primary spontaneous pneumothorax can represent a significant financial burden. Hany Elsayed, MRCS The Cardiothoracic Centre Liverpool 4 Isleham Close Liverpool, L19 4XS United Kingdom e-mail: [email protected]
991
2. Chee CB, Abishaganaden J, Yeo JK, et al. Persistent air-leak in spontaneous pneumothorax— clinical course and outcome. Respir Med 1998;92:757– 61.
Reply To the Editor: We appreciate very much the interest expressed by Dr Elsayed [1] regarding our article on the salvage for unsuccessful aspiration of primary spontaneous pneumothorax [2]. Elsayed [1] raised an important controversy in the management of the first episode of spontaneous pneumothorax. We agree that videoassisted thoracic surgery (VATS) should not be the standard first line of management. In the current practice, both simple aspiration and chest tube drainage (CTD) are acceptable first line managements in patients requiring intervention. In our hospital, we prefer simple aspiration because it is as effective as CTD with reduced morbidity, hospital stay, and the need for hospitalization [3]. Using VATS is usually reserved for patients with recurrence or persistent air leakage. The definition of “persistent” air leakage after CTD is arguable, because almost all primary pneumothoraxes resolve spontaneously within 14 days. To prevent prolonged hospitalization, the American College of Chest Physicians (ACCP) recommends continued observation for 5 days before encouraging the patient to accept a surgical intervention [4]. Several authors, including us, have recommended operative intervention as early as 3 days for a persistent air leak [5]. The definition and management of persistent air leakage after simple aspiration is more contentious. In the guidelines published by the British Thoracic Society, CTD is recommended if repeat aspiration is unsuccessful, without providing any evidence [6]. If we accept that simple aspiration is equally effective as CTD in managing primary spontaneous pneumothorax, why should we choose CTD as the salvage procedure after unsuccessful aspiration? We hypothesize that patients with unsuccessful aspiration represent highly selected individuals with a higher failure rate of treatment even if a chest tube has been placed, and a more effective procedure such as VATS should be considered. In our CTD patients, we perform VATS if air leaks are greater than 72 hours. We agree that VATS costs more medical expenditure when compared with CTD alone. However, if these young, active patients can go back to work or school earlier without fear of prolonged air leakage and recurrence, maybe more social resources can be saved. A prospective, randomized study is recommended to answer the controversy regarding the optimal treatment for patients with unsuccessful simple aspiration. Jin-Shing Chen, MD, PhD Yung-Chie Lee, MD, PhD Department of Surgery National Taiwan University Hospital and National Taiwan University College of Medicine Departments of Surgery and Traumatology No. 7, Chung-Shan South Rd Taipei, 100 Taiwan e-mail: [email protected]
References References 1. Chen JS, Hsu HH, Tsai KT, Yuan A, Chen WJ, Lee YC. Salvage for unsuccessful aspiration of primary pneumothorax: thoracoscopic surgery or chest tube drainage? Ann Thorac Surg 2008;85:1908 –13. © 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
1. Elsayed HH. Should thoracoscopic surgery be the standard management for patients with primary pneumothorax? (letter) Ann Thorac Surg 2009;87:991. 2. Chen JS, Hsu HH, Tsai KT, Yuan A, Chen WJ, Lee YC. Salvage for unsuccessful aspiration of primary pneumothorax: thora0003-4975/09/$36.00
MISCELLANEOUS
after induction chemotherapy. In the light of this discussion, the recently reported data by the German Lung Cancer Cooperative Group are interesting, as they reported a 5-year disease-free survival of 12% in patients with complete resection (ie, lobectomy or pneumonectomy) and persistent N2 disease [2].
CORRESPONDENCE