- Email: [email protected]
Issues in Management of N2 disease in NSCLC
CORRESPONDENCE
Surgical Treatment of Bronchiectasis To the Editor:
Reply To the Editor:
We read with extreme interest the article by Balci and colleagues [1] published in a recent issue of this journal, describing their results and predictive factors in patients with bronchiectasis undergoing surgical therapy. Balci and colleagues [1] performed segmentectomy in patients with poor respiratory function or limited symptoms of bronchiectasis. During pulmonary resection, they avoided excessive dissection, preserved the peribronchial tissues, and covered the stump with mediastinal pleura or tissue. We and many other authors have recently reported that complete resection of all diseased lung segments in bronchiectasis must always be attempted [2]. In a wide series, the postoperative morbidity rate was 11% in cases of complete resection, whereas it was 80% in cases of incomplete resection [3]. In our study of a series of 122 cases of bronchiectasis, after resection, we did not use a flap or any other type of tissue to cover the stump. Bronchopleural fistula has not been observed in our cases [2]. Balci and colleagues [1] reported that they used fiberoptic bronchoscopy (FOB) preoperatively for diagnostic study. FOB dis not necessary for a diagnosis of bronchiectasis. Preoperative FOB is commonly used for the diagnosis of bronchiectasis caused by a foreign body. We performed only 13 FOB for 122 patients, and no problem was seen in any of our patients who did not undergo FOB [2]. Balci and colleagues [1] reported 19 cases of pneumonectomy in 86 patients, which is significantly high. We [2], Eren and colleagues [3], and Balkanli and colleagues [4] reported 7 cases of pneumonectomy in 122 patients, 12 in 143, and 13 in 238, respectively. In Turkey, the incidence of cystic fibrosis (CF) is 1:3000, and patients are expected to live into their 30s [5]. In the series by Balci and colleagues [1], the mean age of the patients was 37.8 14.5 years. Some tests for CF screening were included in this study. In consideration of the very low incidence of CF in Turkey, it seems unnecessary to perform screening tests for CF.
We read with interest the letter by Dr Candas and colleagues [1]. The main cause of bronchiectasis is an infection that may, under various circumstances, continue postoperatively. Covering the stump with well-blooded tissue can increase a patient’s resistance to bronchial opening. When the disease is localized, unnecessarily wide operations can result in further adverse events, including respiratory failure. Patients with limited pulmonary reserve can benefit more from a complete resection of all diseased lung tissue than from a lobectomy or a pneumonectomy. A full resection of all bronchiectatic areas was done for 78 of the 86 patients (90.7%) [2]. Heavy adhesions, mostly caused by old tuberculosis and difficult-to-diagnose pathologic conditions of the lung, may interfere with the complete resection process. We used fiberoptic and rigid bronchoscopy to make observations, clear the airways, and localize the bleeding (if present), not to diagnose the bronchiectasis. Many of the patients came from underdeveloped regions, resulting in delayed diagnosis and lack of consistent medical support. Therefore, the severity of lung destruction usually warranted a pneumonectomy. We observed cystic fibrosis or required special screening in any of our cases.
Fatih Candas, MD Akin Yildizhan, MD Rauf Gorur, MD
Issues in Management of N2 disease in NSCLC To the Editor:
MISCELLANEOUS
Department of Thoracic Surgery GATA Haydarpasa Teaching Hospital Uskudar 34668 Istanbul, Turkey e-mail: [email protected]
References € 1. Balci AE, Balci TA, Ozyurtan MO. Current surgical therapy for bronchiectasis: surgical results and predictive factors in 86 patients. Ann Thorac Surg 2014;97:211–7. 2. Gorur R, Turut H, Yiyit N, et al. The influence of specific factors on postoperative morbidity in young adults with bronchiectasis. Heart Lung Circ 2011;20:468–72. 3. Eren S, Esme H, Avci A. Risk factors affecting outcome and morbidity in the surgical management of bronchiectasis. J Thorac Cardiovasc Surg 2007;134:392–8. 4. Balkanli K, Genc¸ O, Dakak M, et al. Surgical management of bronchiectasis: analysis and short-term results in 238 patients. Eur J Cardiothorac Surg 2003;24:699–702. 5. G€ ung€ or O, Tamay Z, G€ uler N, Erturan Z. Frequency of fungi in respiratory samples from Turkish cystic fibrosis patients. Mycoses 2013;56:123–9. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Akin Eraslan Balci, MD Department of Thoracic Surgery Firat University School of Medicine Elazig, Turkey 23119 e-mail: [email protected]
References 1. Candas F, Yildizhan A, Gorur R. Surgical treatment of bronchiectasis (letter). Ann Thorac Surg 2015;99:744. € 2. Balci AE, Balci TA, Ozyurtan MO. Current surgical therapy for bronchiectasis: surgical results and predictive factors in 86 patients. Ann Thorac Surg 2014;97:211–7.
The recent article in which Cho and colleagues [1] attempt to redefine indications of mediastinoscopy based on various predictive factors brings forth 3 important issues: First, is there really a difference between neoadjuvant and adjuvant chemotherapy in mediastinal node-positive disease? Second, how do we objectively reconcile the obvious outcome differences within heterogeneous N2 disease in non–small cell lung cancer (NSCLC)? Finally, the excellent survival outcomes in this study lay to rest the question of whether surgical intervention is indicated in occult N2 NSCLC. Although we congratulate the authors for demonstrating 66.6% and 36.4% 5-year survival for singlestation and multistation occult N2 disease, respectively, we speculate about their policy of managing “suspected” N2 disease—had mediastinoscopy been performed in all cases, the number of “unsuspected” N2 nodes would have undoubtedly decreased. The authors’ attempt to define a subset of patients in whom mediastinoscopy could be avoided is commendable given that it is a challenging procedure with its own morbidity. One of the controversies in the management of N2 disease (exemplified by the authors’ own institutional practice) is: Does it really matter whether chemotherapy is given in the neoadjuvant setting? Could similar results be obtained even with adjuvant chemotherapy? All the original trials of N2 disease [2] evaluated Ann Thorac Surg 2015;99:744–8 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.118
Ann Thorac Surg 2015;99:744–8
neoadjuvant chemotherapy (NACT) with surgical intervention alone; the current standard of care for operable NSCLC being adjuvant chemotherapy, it is debatable whether the survival “advantage” of NACT in N2 disease would continue to be seen if compared with adjuvant chemotherapy. The meta-analysis on adjuvant chemotherapy in early NSCLC [3], as well as the meta-analysis of NACT in N2 NSCLC [2, 3], showed identical survival differences over surgical intervention alone. If the results of the NATCH trial [4], which showed no survival difference between neoadjuvant and adjuvant chemotherapy in early NSCLC are replicated in N2 disease, there would be no indication for staging mediastinoscopy because there would be no need to identify N2 disease preoperatively. However, until a well-powered randomized trial demonstrates equivalence of neoadjuvant and adjuvant chemotherapy in N2 NSCLC, the need to identify N2 disease reliably before operation still exists. Currently, with the 15% false-negative rate for mediastinal lymph nodes with positron-emission tomography/computed tomography, it may be premature to abandon mediastinoscopy. Tarun Kumar, MCh Sabita Jiwnani, MS, MRCS George Karimundackal, MCh, MRCS C. S. Pramesh, MS, FRCS Division of Thoracic Surgery Department of Surgical Oncology Tata Memorial Centre Mumbai 400012, India e-mail: [email protected]
References 1. Cho HJ, Kim SR, Kim HR, et al. Modern outcome and risk analysis of surgically resected occult N2 non-small cell lung cancer. Ann Thorac Surg 2014;97:1920–5. 2. NSCLC Meta-analysis Collaborative Group. Preoperative chemotherapy for non-small cell lung cancer: a systematic review and meta-analysis of individual participant data. Lancet 2014;383:1561–71. 3. Pignon JP, Tribodet H, Scagliotti GV, et al. Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group. J Clin Oncol 2008;26:3552–5. 4. Felip E, Rosell R, Maestre JA, et al. Preoperative chemotherapy plus surgery versus surgery plus adjuvant chemotherapy versus surgery alone in early-stage non-small-cell lung cancer. J Clin Oncol 2010;28:3138–45.
CORRESPONDENCE
745
modicum of vascular control while dissecting around the pseudoaneurysm during definitive repair. However, we believe that the stent graft must, by definition, be considered temporary given the infected field into which it is placed with inevitable issues of chronic prosthesis infection, re-fistulization and rebleeding if left in situ [2, 3]. In truly inoperable patients, stent grafting can be considered as a palliative maneuver when combined with long-term suppressive antibiotics [4]. We wondered why, 5 months later, their patient remains unrepaired. The report gave no evidence of significant intrathoracic soiling (i.e., mediastinitis, empyema, sepsis), comorbidities, or complications that might mandate such a significant delay to definitive repair. In our experience, repair within days to a week during the same hospital stay is safe, effective, and expeditious. Waiting for several months or longer risks making definitive repair more difficult given scaring induced by endovascular stenting. In addition, fresh stents are easy to remove from the aorta and minimize tissue destruction or loss at the proximal and distal cuffs, which can be disastrous in coarcted aortas. The report ended by suggesting that PET scanning can be useful in determining the need for definitive repair, which contradicts their a priori treatment plan. We would strongly advise against introducing such a decision node in the management algorithm of these patients. We firmly advocate that all surgical candidates treated with this approach undergo definitive repair unless their condition deteriorates such that they are no longer fit for operation. Joshua L. Hermsen, MD Division of Cardiothoracic Surgery University of Washington Medical Center 3011 NE 96th St Seattle, WA 98115 e-mail: [email protected] Matthew P. Sweet, MD Division of Vascular Surgery University of Washington Medical Center Seattle, Washington Michael S. Mulligan, MD Division of Cardiothoracic Surgery University of Washington Medical Center Seattle, Washington
References
We read with interest the recent case report by Myers and colleagues [1] regarding their use of thoracic aortic stent grafting (TEVAR) in the management of a patient with aortoesophageal fistula following coarctation bypass. We commend their approach and excellent early result. We recently treated two patients with similar problems. One patient also had an aortoesophageal fistula following interposition grafting repair for traumatic disruption and another patient had an aortopulmonary fistula following coarctation bypass. Using the “TEVAR-first” approach, both underwent definitive open surgical repair during the same hospitalization. We agree with Myers and colleagues [1] that stent grafting is a key temporizing measure for these patients. It acutely controls and mitigates further hemorrhage, prevents these difficult cases from being done on an emergent basis, and gives a Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1. Myers PO, Gemayel G, Mugnai D, Murith N, Kalangos A. Endovascular exclusion of aortoesophageal fistula after coarctation extraanatomical bypass. Ann Thorac Surg 2014;98: 314–6. 2. Ozaki K, Senada J, Ohtake H, Watanabe G, Matsui O. Successful thoracic endovascular aortic repair of an aortoesophageal fistula. Vascular 2013;21:97–101. 3. Dorweiler B, Weigang E, Duenschede F, et al. Strategies for endovascular aortic repair in aortobronchial and aortoesophageal fistulas. Thorac Cardiovasc Surg 2013;61:575–80. 4. McCarthy MJ. Open or endovascular repair of secondary aortoenteric fistulae? Eur J Vasc Endovasc Surg 2011;41:635–6.
Reply To the Editor: We thank Hermsen and colleagues for their positive and interesting comments on our report on endovascular exclusion of an 0003-4975/$36.00
MISCELLANEOUS
Finish the Job! To the Editor:
Surgical Treatment of Bronchiectasis To the Editor:
Reply To the Editor:
We read with extreme interest the article by Balci and colleagues [1] published in a recent issue of this journal, describing their results and predictive factors in patients with bronchiectasis undergoing surgical therapy. Balci and colleagues [1] performed segmentectomy in patients with poor respiratory function or limited symptoms of bronchiectasis. During pulmonary resection, they avoided excessive dissection, preserved the peribronchial tissues, and covered the stump with mediastinal pleura or tissue. We and many other authors have recently reported that complete resection of all diseased lung segments in bronchiectasis must always be attempted [2]. In a wide series, the postoperative morbidity rate was 11% in cases of complete resection, whereas it was 80% in cases of incomplete resection [3]. In our study of a series of 122 cases of bronchiectasis, after resection, we did not use a flap or any other type of tissue to cover the stump. Bronchopleural fistula has not been observed in our cases [2]. Balci and colleagues [1] reported that they used fiberoptic bronchoscopy (FOB) preoperatively for diagnostic study. FOB dis not necessary for a diagnosis of bronchiectasis. Preoperative FOB is commonly used for the diagnosis of bronchiectasis caused by a foreign body. We performed only 13 FOB for 122 patients, and no problem was seen in any of our patients who did not undergo FOB [2]. Balci and colleagues [1] reported 19 cases of pneumonectomy in 86 patients, which is significantly high. We [2], Eren and colleagues [3], and Balkanli and colleagues [4] reported 7 cases of pneumonectomy in 122 patients, 12 in 143, and 13 in 238, respectively. In Turkey, the incidence of cystic fibrosis (CF) is 1:3000, and patients are expected to live into their 30s [5]. In the series by Balci and colleagues [1], the mean age of the patients was 37.8 14.5 years. Some tests for CF screening were included in this study. In consideration of the very low incidence of CF in Turkey, it seems unnecessary to perform screening tests for CF.
We read with interest the letter by Dr Candas and colleagues [1]. The main cause of bronchiectasis is an infection that may, under various circumstances, continue postoperatively. Covering the stump with well-blooded tissue can increase a patient’s resistance to bronchial opening. When the disease is localized, unnecessarily wide operations can result in further adverse events, including respiratory failure. Patients with limited pulmonary reserve can benefit more from a complete resection of all diseased lung tissue than from a lobectomy or a pneumonectomy. A full resection of all bronchiectatic areas was done for 78 of the 86 patients (90.7%) [2]. Heavy adhesions, mostly caused by old tuberculosis and difficult-to-diagnose pathologic conditions of the lung, may interfere with the complete resection process. We used fiberoptic and rigid bronchoscopy to make observations, clear the airways, and localize the bleeding (if present), not to diagnose the bronchiectasis. Many of the patients came from underdeveloped regions, resulting in delayed diagnosis and lack of consistent medical support. Therefore, the severity of lung destruction usually warranted a pneumonectomy. We observed cystic fibrosis or required special screening in any of our cases.
Fatih Candas, MD Akin Yildizhan, MD Rauf Gorur, MD
Issues in Management of N2 disease in NSCLC To the Editor:
MISCELLANEOUS
Department of Thoracic Surgery GATA Haydarpasa Teaching Hospital Uskudar 34668 Istanbul, Turkey e-mail: [email protected]
References € 1. Balci AE, Balci TA, Ozyurtan MO. Current surgical therapy for bronchiectasis: surgical results and predictive factors in 86 patients. Ann Thorac Surg 2014;97:211–7. 2. Gorur R, Turut H, Yiyit N, et al. The influence of specific factors on postoperative morbidity in young adults with bronchiectasis. Heart Lung Circ 2011;20:468–72. 3. Eren S, Esme H, Avci A. Risk factors affecting outcome and morbidity in the surgical management of bronchiectasis. J Thorac Cardiovasc Surg 2007;134:392–8. 4. Balkanli K, Genc¸ O, Dakak M, et al. Surgical management of bronchiectasis: analysis and short-term results in 238 patients. Eur J Cardiothorac Surg 2003;24:699–702. 5. G€ ung€ or O, Tamay Z, G€ uler N, Erturan Z. Frequency of fungi in respiratory samples from Turkish cystic fibrosis patients. Mycoses 2013;56:123–9. Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Akin Eraslan Balci, MD Department of Thoracic Surgery Firat University School of Medicine Elazig, Turkey 23119 e-mail: [email protected]
References 1. Candas F, Yildizhan A, Gorur R. Surgical treatment of bronchiectasis (letter). Ann Thorac Surg 2015;99:744. € 2. Balci AE, Balci TA, Ozyurtan MO. Current surgical therapy for bronchiectasis: surgical results and predictive factors in 86 patients. Ann Thorac Surg 2014;97:211–7.
The recent article in which Cho and colleagues [1] attempt to redefine indications of mediastinoscopy based on various predictive factors brings forth 3 important issues: First, is there really a difference between neoadjuvant and adjuvant chemotherapy in mediastinal node-positive disease? Second, how do we objectively reconcile the obvious outcome differences within heterogeneous N2 disease in non–small cell lung cancer (NSCLC)? Finally, the excellent survival outcomes in this study lay to rest the question of whether surgical intervention is indicated in occult N2 NSCLC. Although we congratulate the authors for demonstrating 66.6% and 36.4% 5-year survival for singlestation and multistation occult N2 disease, respectively, we speculate about their policy of managing “suspected” N2 disease—had mediastinoscopy been performed in all cases, the number of “unsuspected” N2 nodes would have undoubtedly decreased. The authors’ attempt to define a subset of patients in whom mediastinoscopy could be avoided is commendable given that it is a challenging procedure with its own morbidity. One of the controversies in the management of N2 disease (exemplified by the authors’ own institutional practice) is: Does it really matter whether chemotherapy is given in the neoadjuvant setting? Could similar results be obtained even with adjuvant chemotherapy? All the original trials of N2 disease [2] evaluated Ann Thorac Surg 2015;99:744–8 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.04.118
Ann Thorac Surg 2015;99:744–8
neoadjuvant chemotherapy (NACT) with surgical intervention alone; the current standard of care for operable NSCLC being adjuvant chemotherapy, it is debatable whether the survival “advantage” of NACT in N2 disease would continue to be seen if compared with adjuvant chemotherapy. The meta-analysis on adjuvant chemotherapy in early NSCLC [3], as well as the meta-analysis of NACT in N2 NSCLC [2, 3], showed identical survival differences over surgical intervention alone. If the results of the NATCH trial [4], which showed no survival difference between neoadjuvant and adjuvant chemotherapy in early NSCLC are replicated in N2 disease, there would be no indication for staging mediastinoscopy because there would be no need to identify N2 disease preoperatively. However, until a well-powered randomized trial demonstrates equivalence of neoadjuvant and adjuvant chemotherapy in N2 NSCLC, the need to identify N2 disease reliably before operation still exists. Currently, with the 15% false-negative rate for mediastinal lymph nodes with positron-emission tomography/computed tomography, it may be premature to abandon mediastinoscopy. Tarun Kumar, MCh Sabita Jiwnani, MS, MRCS George Karimundackal, MCh, MRCS C. S. Pramesh, MS, FRCS Division of Thoracic Surgery Department of Surgical Oncology Tata Memorial Centre Mumbai 400012, India e-mail: [email protected]
References 1. Cho HJ, Kim SR, Kim HR, et al. Modern outcome and risk analysis of surgically resected occult N2 non-small cell lung cancer. Ann Thorac Surg 2014;97:1920–5. 2. NSCLC Meta-analysis Collaborative Group. Preoperative chemotherapy for non-small cell lung cancer: a systematic review and meta-analysis of individual participant data. Lancet 2014;383:1561–71. 3. Pignon JP, Tribodet H, Scagliotti GV, et al. Lung adjuvant cisplatin evaluation: a pooled analysis by the LACE Collaborative Group. J Clin Oncol 2008;26:3552–5. 4. Felip E, Rosell R, Maestre JA, et al. Preoperative chemotherapy plus surgery versus surgery plus adjuvant chemotherapy versus surgery alone in early-stage non-small-cell lung cancer. J Clin Oncol 2010;28:3138–45.
CORRESPONDENCE
745
modicum of vascular control while dissecting around the pseudoaneurysm during definitive repair. However, we believe that the stent graft must, by definition, be considered temporary given the infected field into which it is placed with inevitable issues of chronic prosthesis infection, re-fistulization and rebleeding if left in situ [2, 3]. In truly inoperable patients, stent grafting can be considered as a palliative maneuver when combined with long-term suppressive antibiotics [4]. We wondered why, 5 months later, their patient remains unrepaired. The report gave no evidence of significant intrathoracic soiling (i.e., mediastinitis, empyema, sepsis), comorbidities, or complications that might mandate such a significant delay to definitive repair. In our experience, repair within days to a week during the same hospital stay is safe, effective, and expeditious. Waiting for several months or longer risks making definitive repair more difficult given scaring induced by endovascular stenting. In addition, fresh stents are easy to remove from the aorta and minimize tissue destruction or loss at the proximal and distal cuffs, which can be disastrous in coarcted aortas. The report ended by suggesting that PET scanning can be useful in determining the need for definitive repair, which contradicts their a priori treatment plan. We would strongly advise against introducing such a decision node in the management algorithm of these patients. We firmly advocate that all surgical candidates treated with this approach undergo definitive repair unless their condition deteriorates such that they are no longer fit for operation. Joshua L. Hermsen, MD Division of Cardiothoracic Surgery University of Washington Medical Center 3011 NE 96th St Seattle, WA 98115 e-mail: [email protected] Matthew P. Sweet, MD Division of Vascular Surgery University of Washington Medical Center Seattle, Washington Michael S. Mulligan, MD Division of Cardiothoracic Surgery University of Washington Medical Center Seattle, Washington
References
We read with interest the recent case report by Myers and colleagues [1] regarding their use of thoracic aortic stent grafting (TEVAR) in the management of a patient with aortoesophageal fistula following coarctation bypass. We commend their approach and excellent early result. We recently treated two patients with similar problems. One patient also had an aortoesophageal fistula following interposition grafting repair for traumatic disruption and another patient had an aortopulmonary fistula following coarctation bypass. Using the “TEVAR-first” approach, both underwent definitive open surgical repair during the same hospitalization. We agree with Myers and colleagues [1] that stent grafting is a key temporizing measure for these patients. It acutely controls and mitigates further hemorrhage, prevents these difficult cases from being done on an emergent basis, and gives a Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
1. Myers PO, Gemayel G, Mugnai D, Murith N, Kalangos A. Endovascular exclusion of aortoesophageal fistula after coarctation extraanatomical bypass. Ann Thorac Surg 2014;98: 314–6. 2. Ozaki K, Senada J, Ohtake H, Watanabe G, Matsui O. Successful thoracic endovascular aortic repair of an aortoesophageal fistula. Vascular 2013;21:97–101. 3. Dorweiler B, Weigang E, Duenschede F, et al. Strategies for endovascular aortic repair in aortobronchial and aortoesophageal fistulas. Thorac Cardiovasc Surg 2013;61:575–80. 4. McCarthy MJ. Open or endovascular repair of secondary aortoenteric fistulae? Eur J Vasc Endovasc Surg 2011;41:635–6.
Reply To the Editor: We thank Hermsen and colleagues for their positive and interesting comments on our report on endovascular exclusion of an 0003-4975/$36.00
MISCELLANEOUS
Finish the Job! To the Editor: