- Email: [email protected]
Is There a Role for Preoperative Chemoradiation in Esophageal Signet Ring Cell Adenocarcinomas?
CORRESPONDENCE
Optimal Lung Cancer Candidates for Sublobar Resection: Prediction of Pathologic Node-Negative Clinical Stage IA NSCLC To the Editor: We read with interest the article by Ye and colleagues [1] about the predictive factors for lymph node metastasis in clinical stage IA lung adenocarcinoma, in which they reported a 10.6% overall rate of lymph node metastasis. Theoretically, candidates for sublobar resection should be node negative; thus, it is important to improve the accuracy of clinical staging for cancer. According to the data of Ye and colleagues, factors such as ground-glass opacity status, serum carcinoembryonic antigen level, histologic subtype, and maximum standardized uptake value have potential for the prediction of lymph node metastasis. A prediction model based on some of these factors has been established to assess the possibility of lymph node metastasis in early-stage lung cancer [2]. Some issues are worth noting here. First, the specific histology subtype (eg, acinar predominant, micropapillary predominant) was a reliable predictive factor both in the study of Ye and colleagues and in other research [3]. However, for the majority of lung cancer patients, the histology subtype is a postoperative pathologic diagnosis that is difficult to determine before operation because of the lack of a sufficient tumor specimen, so the histology subtype is of limited value for excluding nodepositive patients preoperatively. Second, according to their univariate analyses, the node metastasis rates for patients with individual risk factors were less than 20%, suggesting that these predictive factors are insufficiently efficient for excluding nodepositive patients. Two approaches have potential value in selecting candidates for sublobar resection. One is to identify high-risk patients for lymph node metastasis, followed by mediastinal staging evaluation. The other is the use of lymphatic tracers for sentinel lymph node mapping. A clinical study has demonstrated that an indocyanine green fluorescence imaging system is feasible for use in sentinel node biopsy and has a high overall accuracy rate of 80.7% [4]. Optimization of the imaging system and lymphatic tracers for the sentinel lymph nodes would provide an accurate means of determining the optimal candidates for sublobar resection. We eagerly await the further development and refinement of this technology. Again, we congratulate Ye and colleagues on this brilliant study. We are confident that this study will optimize the selection of candidates for either invasive mediastinal staging or sublobar resection.
Department of Thoracic Surgery First Hospital, Zhejiang University No. 79, Qingchun Rd Hangzhou, 310003 Zhejiang, China e-mail: [email protected]
References 1. Ye B, Cheng M, Li W, et al. Predictive factors for lymph node metastasis in clinical stage Ia lung adenocarcinoma. Ann Thorac Surg 2014;98:217–23.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Is There a Role for Preoperative Chemoradiation in Esophageal Signet Ring Cell Adenocarcinomas? To the Editor: In a recently published study, Patel and colleagues [1] examined the significance of signet ring cell (SRC) histologic appearance to predict response to neoadjuvant chemoradiotherapy (NCRT) in patients with esophageal adenocarcinoma. Some qualifications need to be made regarding the interpretation of the results. First, although the authors showed a higher positive resection margin rate (24% vs 10%) in SRC patients, it is surprising that the margin status was not included in the multivariate analysis of survival. The proposal to perform a frozen section analysis to decrease the rate of incomplete resection seems tempting. However, frozen section analysis is poorly reliable in SRC tumors. To overcome this limitation, a total gastrectomy with an extended esophagectomy and intrathoracic esojejunal anastomosis to maximize the chance of a disease-free surgical margin may be proposed [2]. Second, based on the absence of statistical differences, the authors concluded that there was no survival benefit in downstaged SRC patients. However, the survival curves appear different, and a type II error linked to small numbers may explain the results. Third, it is argued that the pretreatment clinical staging did not differ between groups. However, the reliability of pretherapeutic TNM staging has been questioned in SRC tumors, which have a higher affinity for lymphatic spread and peritoneal seeding because of their infiltrating nature [2]. This may be responsible for more advanced tumors in SRC histology and explain the apparent lower response rate to NCRT. Finally, before the authors can propose primary surgical treatment for SRC cT2 or cN0 tumors, a direct comparison between primary surgical treatment and NCRT followed by surgical treatment should be performed. We recently published a study suggesting that NCRT should be the preferred therapeutic strategy to adopt in locally advanced SRC tumors of the esophagogastric junction [3]. We acknowledge that the optimal treatment of esophagogastric SRC tumors will remain controversial until evidence becomes available from phase 3 randomized trials dedicated to SRC histology, as is currently being investigated by our group for gastric tumors (PRODIGE-19FFCD1103-ADCI002 trial) [2]. Caroline Gronnier, MD, PhD Sarah Bekkar, MD Mathieu Messager, MD Guillaume Piessen, MD, PhD Christophe Mariette, MD, PhD Department of Digestive and Oncological Surgery University Hospital Claude Huriez Centre Hospitalier Regional Universitaire Place de Verdun F-59037 Lille, France e-mail: [email protected]
Ann Thorac Surg 2015;99:2253–7 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.030
MISCELLANEOUS
Feichao Bao, MD Abudumailamu Abuduwufuer, MD Xiaoshuai Yuan, MD Xiayi Lv, MD Jian Hu, MD
2. Zhang Y, Sun Y, Xiang J, Hu H, Chen H. A prediction model for n2 disease in T1 non-small cell lung cancer. J Thorac Cardiovasc Surg 2012;144:1360–4. 3. Zhang Y, Sun Y, Shen L, et al. Predictive factors of lymph node status in small peripheral non-small cell lung cancers: tumor histology is more reliable. Ann Surg Oncol 2013;20:1949–54. 4. Yamashita S, Tokuishi K, Anami K, et al. Video-assisted thoracoscopic indocyanine green fluorescence imaging system shows sentinel lymph nodes in non-small-cell lung cancer. J Thorac Cardiovasc Surg 2011;141:141–4.
2254
CORRESPONDENCE
References 1. Patel VR, Hofstetter WL, Correa AM, et al. Signet ring cells in esophageal adenocarcinoma predict poor response to preoperative chemoradiation. Ann Thorac Surg 2014;98: 1064–71. 2. Piessen G, Messager M, Robb WB, Bonnetain F, Mariette C. Gastric signet ring cell carcinoma: how to investigate its impact on survival. J Clin Oncol 2013;31:2059–60. 3. Bekkar S, Gronnier C, Messager M, et al. The impact of preoperative radiochemotherapy on survival in advanced esophagogastric junction signet ring cell adenocarcinoma. Ann Thorac Surg 2014;97:303–10.
Robotic Resection of Accessory Mitral Valve Tissue To the Editor: We read with interest the article by Yamaguchi and colleagues describing the resection of accessory mitral valve tissue in an adult using robotic instrumentation [1]. We congratulate this team on their successful procedure. It is not, however, as they claim the first report of successful robotic resection of accessory mitral tissue. We described an almost identical case in 2006 [2]. Using a lateral endoscopic robotic approach, we partially detached the anterior mitral leaflet, excised the accessory mitral leaflet from the left ventricular outflow tract, and repaired the leaflet with autologous pericardium. The patient remains asymptomatic 8 years later. In our report we predicted that the lateral endoscopic approach using robotics would be useful for lesions of the left ventricular outflow tract, and we are gratified to see its successful application by Dr Yamaguchi’s team. Douglas A. Murphy, MD Department of Cardiothoracic Surgery Emory St. Joseph’s Hospital of Atlanta 5665 Peachtree Dunwoody Rd Atlanta, GA 30342 e-mail: [email protected]
Ann Thorac Surg 2015;99:2253–7
Takara-machi 13-1 Kanazawa, Japan 920-8641 e-mail: [email protected]
References 1. Murphy DA. Robotic resection of accessory mitral valve tissue (letter). Ann Thorac Surg 2015;99:2254. 2. Yamaguchi S, Ishikawa N, Tomita S, et al. Robotic resection of dual accessory mitral valve tissue in an adult patient. Ann Thorac Surg 2014;98:1096–8.
Subdermal Contraceptive Implant Embolism to a Pulmonary Artery To the Editor: We read with interest the recent case report of Patel and colleagues [1] describing the embolization of a subdermal contraceptive implant to a pulmonary artery. A 23-year-old woman came to our emergency department with dyspnea. A chest radiogram identified a left pneumothorax and a linear opacity in the left lower lung zone. Computed tomography (CT) of the thorax (Fig 1) confirmed a 4-cm radiopaque foreign body within a segmental branch of the left lower lobe pulmonary artery. The patient had had a subdermal contraceptive implant, Implanon (etonogestrel) (Merek Inc, Ireland) inserted 2 years previously into the medial aspect of her upper left arm. Examination, roentgenology, and ultrasonography of the patient’s arm failed to identify the device, and it was deduced that the subdermal contraceptive implant had embolized to the pulmonary artery. The patient wished to start a family, and wanted the contraceptive device removed. Patel and colleagues [1] suggested that endovascular retrieval may be feasible. We attempted endovascular retrieval by selective catheterization of the left lower pulmonary artery, using
Dr Murphy discloses a financial relationship with Intuitive Surgical.
MISCELLANEOUS
References 1. Yamaguchi S, Ishikawa N, Tomita S, et al. Robotic resection of dual accessory mitral valve tissue in an adult patient. Ann Thorac Surg 2014;98:1096–8. 2. Murphy D, Byrne J, Malave H. Robotic endoscopic excision of accessory mitral leaflet. J Thorac Cardiovascular Surg 2006;131:468–9.
Reply To the Editor: Thank you for pointing out a good suggestion from Dr Murphy and colleagues [1], which is a nice piece of work. As they acknowledged, our work [2] is the first report about “dual” accessory mitral valve tissue. As we realize, excision of accessory mitral valve tissue may be difficult; thus, a robotic procedure with a high resolution camera may make it easier. Shojiro Yamaguchi, MD, PhD Department of General and Cardiothoracic Surgery Kanazawa University School of Medicine Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Coronal noncontrast computed tomography demonstrates an intravascular foreign body within a segmental branch of the left pulmonary artery. There is a small left pneumothorax. 0003-4975/$36.00
Optimal Lung Cancer Candidates for Sublobar Resection: Prediction of Pathologic Node-Negative Clinical Stage IA NSCLC To the Editor: We read with interest the article by Ye and colleagues [1] about the predictive factors for lymph node metastasis in clinical stage IA lung adenocarcinoma, in which they reported a 10.6% overall rate of lymph node metastasis. Theoretically, candidates for sublobar resection should be node negative; thus, it is important to improve the accuracy of clinical staging for cancer. According to the data of Ye and colleagues, factors such as ground-glass opacity status, serum carcinoembryonic antigen level, histologic subtype, and maximum standardized uptake value have potential for the prediction of lymph node metastasis. A prediction model based on some of these factors has been established to assess the possibility of lymph node metastasis in early-stage lung cancer [2]. Some issues are worth noting here. First, the specific histology subtype (eg, acinar predominant, micropapillary predominant) was a reliable predictive factor both in the study of Ye and colleagues and in other research [3]. However, for the majority of lung cancer patients, the histology subtype is a postoperative pathologic diagnosis that is difficult to determine before operation because of the lack of a sufficient tumor specimen, so the histology subtype is of limited value for excluding nodepositive patients preoperatively. Second, according to their univariate analyses, the node metastasis rates for patients with individual risk factors were less than 20%, suggesting that these predictive factors are insufficiently efficient for excluding nodepositive patients. Two approaches have potential value in selecting candidates for sublobar resection. One is to identify high-risk patients for lymph node metastasis, followed by mediastinal staging evaluation. The other is the use of lymphatic tracers for sentinel lymph node mapping. A clinical study has demonstrated that an indocyanine green fluorescence imaging system is feasible for use in sentinel node biopsy and has a high overall accuracy rate of 80.7% [4]. Optimization of the imaging system and lymphatic tracers for the sentinel lymph nodes would provide an accurate means of determining the optimal candidates for sublobar resection. We eagerly await the further development and refinement of this technology. Again, we congratulate Ye and colleagues on this brilliant study. We are confident that this study will optimize the selection of candidates for either invasive mediastinal staging or sublobar resection.
Department of Thoracic Surgery First Hospital, Zhejiang University No. 79, Qingchun Rd Hangzhou, 310003 Zhejiang, China e-mail: [email protected]
References 1. Ye B, Cheng M, Li W, et al. Predictive factors for lymph node metastasis in clinical stage Ia lung adenocarcinoma. Ann Thorac Surg 2014;98:217–23.
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Is There a Role for Preoperative Chemoradiation in Esophageal Signet Ring Cell Adenocarcinomas? To the Editor: In a recently published study, Patel and colleagues [1] examined the significance of signet ring cell (SRC) histologic appearance to predict response to neoadjuvant chemoradiotherapy (NCRT) in patients with esophageal adenocarcinoma. Some qualifications need to be made regarding the interpretation of the results. First, although the authors showed a higher positive resection margin rate (24% vs 10%) in SRC patients, it is surprising that the margin status was not included in the multivariate analysis of survival. The proposal to perform a frozen section analysis to decrease the rate of incomplete resection seems tempting. However, frozen section analysis is poorly reliable in SRC tumors. To overcome this limitation, a total gastrectomy with an extended esophagectomy and intrathoracic esojejunal anastomosis to maximize the chance of a disease-free surgical margin may be proposed [2]. Second, based on the absence of statistical differences, the authors concluded that there was no survival benefit in downstaged SRC patients. However, the survival curves appear different, and a type II error linked to small numbers may explain the results. Third, it is argued that the pretreatment clinical staging did not differ between groups. However, the reliability of pretherapeutic TNM staging has been questioned in SRC tumors, which have a higher affinity for lymphatic spread and peritoneal seeding because of their infiltrating nature [2]. This may be responsible for more advanced tumors in SRC histology and explain the apparent lower response rate to NCRT. Finally, before the authors can propose primary surgical treatment for SRC cT2 or cN0 tumors, a direct comparison between primary surgical treatment and NCRT followed by surgical treatment should be performed. We recently published a study suggesting that NCRT should be the preferred therapeutic strategy to adopt in locally advanced SRC tumors of the esophagogastric junction [3]. We acknowledge that the optimal treatment of esophagogastric SRC tumors will remain controversial until evidence becomes available from phase 3 randomized trials dedicated to SRC histology, as is currently being investigated by our group for gastric tumors (PRODIGE-19FFCD1103-ADCI002 trial) [2]. Caroline Gronnier, MD, PhD Sarah Bekkar, MD Mathieu Messager, MD Guillaume Piessen, MD, PhD Christophe Mariette, MD, PhD Department of Digestive and Oncological Surgery University Hospital Claude Huriez Centre Hospitalier Regional Universitaire Place de Verdun F-59037 Lille, France e-mail: [email protected]
Ann Thorac Surg 2015;99:2253–7 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.11.030
MISCELLANEOUS
Feichao Bao, MD Abudumailamu Abuduwufuer, MD Xiaoshuai Yuan, MD Xiayi Lv, MD Jian Hu, MD
2. Zhang Y, Sun Y, Xiang J, Hu H, Chen H. A prediction model for n2 disease in T1 non-small cell lung cancer. J Thorac Cardiovasc Surg 2012;144:1360–4. 3. Zhang Y, Sun Y, Shen L, et al. Predictive factors of lymph node status in small peripheral non-small cell lung cancers: tumor histology is more reliable. Ann Surg Oncol 2013;20:1949–54. 4. Yamashita S, Tokuishi K, Anami K, et al. Video-assisted thoracoscopic indocyanine green fluorescence imaging system shows sentinel lymph nodes in non-small-cell lung cancer. J Thorac Cardiovasc Surg 2011;141:141–4.
2254
CORRESPONDENCE
References 1. Patel VR, Hofstetter WL, Correa AM, et al. Signet ring cells in esophageal adenocarcinoma predict poor response to preoperative chemoradiation. Ann Thorac Surg 2014;98: 1064–71. 2. Piessen G, Messager M, Robb WB, Bonnetain F, Mariette C. Gastric signet ring cell carcinoma: how to investigate its impact on survival. J Clin Oncol 2013;31:2059–60. 3. Bekkar S, Gronnier C, Messager M, et al. The impact of preoperative radiochemotherapy on survival in advanced esophagogastric junction signet ring cell adenocarcinoma. Ann Thorac Surg 2014;97:303–10.
Robotic Resection of Accessory Mitral Valve Tissue To the Editor: We read with interest the article by Yamaguchi and colleagues describing the resection of accessory mitral valve tissue in an adult using robotic instrumentation [1]. We congratulate this team on their successful procedure. It is not, however, as they claim the first report of successful robotic resection of accessory mitral tissue. We described an almost identical case in 2006 [2]. Using a lateral endoscopic robotic approach, we partially detached the anterior mitral leaflet, excised the accessory mitral leaflet from the left ventricular outflow tract, and repaired the leaflet with autologous pericardium. The patient remains asymptomatic 8 years later. In our report we predicted that the lateral endoscopic approach using robotics would be useful for lesions of the left ventricular outflow tract, and we are gratified to see its successful application by Dr Yamaguchi’s team. Douglas A. Murphy, MD Department of Cardiothoracic Surgery Emory St. Joseph’s Hospital of Atlanta 5665 Peachtree Dunwoody Rd Atlanta, GA 30342 e-mail: [email protected]
Ann Thorac Surg 2015;99:2253–7
Takara-machi 13-1 Kanazawa, Japan 920-8641 e-mail: [email protected]
References 1. Murphy DA. Robotic resection of accessory mitral valve tissue (letter). Ann Thorac Surg 2015;99:2254. 2. Yamaguchi S, Ishikawa N, Tomita S, et al. Robotic resection of dual accessory mitral valve tissue in an adult patient. Ann Thorac Surg 2014;98:1096–8.
Subdermal Contraceptive Implant Embolism to a Pulmonary Artery To the Editor: We read with interest the recent case report of Patel and colleagues [1] describing the embolization of a subdermal contraceptive implant to a pulmonary artery. A 23-year-old woman came to our emergency department with dyspnea. A chest radiogram identified a left pneumothorax and a linear opacity in the left lower lung zone. Computed tomography (CT) of the thorax (Fig 1) confirmed a 4-cm radiopaque foreign body within a segmental branch of the left lower lobe pulmonary artery. The patient had had a subdermal contraceptive implant, Implanon (etonogestrel) (Merek Inc, Ireland) inserted 2 years previously into the medial aspect of her upper left arm. Examination, roentgenology, and ultrasonography of the patient’s arm failed to identify the device, and it was deduced that the subdermal contraceptive implant had embolized to the pulmonary artery. The patient wished to start a family, and wanted the contraceptive device removed. Patel and colleagues [1] suggested that endovascular retrieval may be feasible. We attempted endovascular retrieval by selective catheterization of the left lower pulmonary artery, using
Dr Murphy discloses a financial relationship with Intuitive Surgical.
MISCELLANEOUS
References 1. Yamaguchi S, Ishikawa N, Tomita S, et al. Robotic resection of dual accessory mitral valve tissue in an adult patient. Ann Thorac Surg 2014;98:1096–8. 2. Murphy D, Byrne J, Malave H. Robotic endoscopic excision of accessory mitral leaflet. J Thorac Cardiovascular Surg 2006;131:468–9.
Reply To the Editor: Thank you for pointing out a good suggestion from Dr Murphy and colleagues [1], which is a nice piece of work. As they acknowledged, our work [2] is the first report about “dual” accessory mitral valve tissue. As we realize, excision of accessory mitral valve tissue may be difficult; thus, a robotic procedure with a high resolution camera may make it easier. Shojiro Yamaguchi, MD, PhD Department of General and Cardiothoracic Surgery Kanazawa University School of Medicine Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Fig 1. Coronal noncontrast computed tomography demonstrates an intravascular foreign body within a segmental branch of the left pulmonary artery. There is a small left pneumothorax. 0003-4975/$36.00