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Lung cancer with pleural dissemination: why not operation?
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CORRESPONDENCE
Lung Cancer With Pleural Dissemination: Why Not Operation? To the Editor: In a recent issue, Sawabata and colleagues [1] reported on operation for non-small cell lung cancer (NSCLC) with malignant pleural effusion detected at thoracotomy. They concluded that tumor resection was not beneficial for survival of these patients. This conclusion could discourage, and even contraindicate any attempt at resection. However, in their series, 5-year survivors were observed when either complete or incomplete resections were performed. From 1984 to 1999, we operated on 38 patients for NSCLC whose preoperative workup did not disclose any contraindication in our department. At thoracotomy, we were surprised to discover macroscopic pleural dissemination. The thoracotomy remained exploratory in 20 patients (survival: median, 13 months; 5 years, 0%). A lung resection with pleurectomy and mediastinal lymph node dissection was performed in 18 patients (survival: median, 31 months; 5 years, 21%). The difference in survival was significant (p ⫽ 0.009) between groups. In a multicentric study, Ichinose and colleagues [2] reported similar results (collected cases n ⫽ 227). According to Ohta and associates [3], a limited operation for local control in such patients is sufficient. We also observed this in our small series: median survival after pneumonectomy (n ⫽ 5), 24 months and after lobectomy (n ⫽ 13), 33 months. Pleural dissemination in the absence of other metastatic disease is probably a particular entity that resembles pleural cavity seeding due to visceral pleural involvement [4], or possibly a latter stage. The NSCLC pleural dissemination is an interesting topic deserving much more consideration. Operation must not be discouraged. Few articles deal with this subject. Reyes and colleagues [5], who were among the first to report success after operation, demonstrated the correct course when they pointed out that the most logical therapeutic approach is neoadjuvant chemotherapy. At the end of their article, Sawabata and colleagues [1] suggest a trial of multimodality treatment for patients with NSCLC with malignant effusion. We believe trials are not only warranted but necessary because they may offer a chance of cure. This does not apply only to unsuspected malignancy discovered at thoracotomy, but should encompass other NSCLC with pleural effusion. This requires suitable patient selection for such trials and the need to convince physicians and oncologists of the possibility of adjuvant operation and not just drainage of the pleural effusion with or without pleurodesis with sclerosing agents. Marc Riquet, PhD, MD Christophe Foucault, MD Franc¸ ois Souilamas, MD Service de Chirurgie Thoracique Hoˆ pital Europe´ en Georges Pompidou 75015 Paris, France e-mail: [email protected]
References 1. Sawabata N, Matsumura A, Motohiro A, et al. Malignant minor pleural effusion detected on thoracotomy for patients with non-small cell lung cancer: is tumor resection beneficial for prognosis? Ann Thorac Surg 2002;73:412–5. 2. Ichinose Y, Tsuchiya R, Koike T, et al. The prognosis of patients with non-small cell lung cancer found to have carcinomatous pleuritis at thoracotomy. Surg Today 2000;30:1062–6. © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;74:1747–50
3. Ohta Y, Tanaka Y, Hara T, et al. Clinicopathological and biological assessment of lung cancers with pleural dissemination. Ann Thorac Surg 2002;69:1025–9. 4. Manac’h D, Riquet M, Medioni J, et al. Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor. Ann Thorac Surg 2001;71:1088 –93. 5. Reyes L, Parvez Z, Regal AM, Takita H. Neoadjuvant chemotherapy and operations in the treatment of lung cancer with pleural effusion (letter). J Thorac Cardiovasc Surg 1991;101:946–7.
Reply To the Editor: I read a response from Riquet and colleagues to our article [1], which reported operation for non-small cell lung cancer (NSCLC) with malignant minor pleural effusion detected at thoracotomy. They pointed out that the 5-year survival rate for patients with pleural involvement was approximately 20% in other studies [2, 3], and that operation should not be discouraged. However, the number of patients who underwent adjuvant therapy was high in these studies. The reason why our completely resected group of patients had a poor survival rate may be due not only to no adjuvant therapy but also a high rate of p1 or p2, which often is associated with a high rate of malignant pleural effusion. Malignant cells in the pleural effusion may arrive from the visceral pleura above a NSCLC. Tumor cells are detected on the pleura above a NSCLC in 20% to 30% of patients [4, 5]. Therefore, it is very difficult to distinguish frank malignant effusion from a contaminated effusion. Although pleural involvement is a poor prognostic factor [6], survival rate may be different between contaminated and primary pleural effusions. Notwithstanding contaminated or primary effusions, malignant pleural effusion indicates a poor prognosis. However, I believe that operation for NSCLC with malignant pleural effusion should not be discouraged but should be tried with adjuvant or induction therapy. Trials of multimordality treatment may offer a good chance of survival in patients with NSCLC with pleural involvement alone and no distant metastasis. Noriyoshi Sawabata, MD Division of Surgery Toneyama National Hospital 5-1-1 Toneyama, Toyonaka, Osaka 560-8552, Japan e-mail: [email protected]
References 1. Sawabata N, Matsumura A, Motohiro A, et al. Malignant minor pleural effusion detected on thoracotomy for patients with non-small cell lung cancer: is tumor resection beneficial for prognosis? Ann Thorac Surg 2002;73:412–5. 2. Ichinose Y, Tsuchiya R, Koike T, et al. The prognosis of patients with non-small cell lung cancer found to have carcinomatous pleuritis at thoracotomy. Surg Today 2000;30:1062–6. 3. Ohta Y, Tanaka Y, Hara T, et al. Clinicopathological and biological assessment of lung cancers with pleural dissemination. Ann Thorac Surg 2000;69:1025–9. 4. Ichinose Y, Yano T, Asoh H, Yokoyama H, Fukuyama Y, Katsuda Y. Diagnosis of visceral pleural invasion in resected lung cancer using a jet stream of saline solution. Ann Thorac Surg 1997;64:1626 –9. 5. Sawabata N, Ohta M, Maeda H. Fine-needle aspiration cytologic technique for lung cancer has a high potential of malignant cell spread through the tract. Chest 2000;118:936 –9. 6. Manac’h D, Riquet M, Medioni J, et al. Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor. Ann Thorac Surg 2001;71:1088 –93. 0003-4975/02/$22.00
CORRESPONDENCE
Lung Cancer With Pleural Dissemination: Why Not Operation? To the Editor: In a recent issue, Sawabata and colleagues [1] reported on operation for non-small cell lung cancer (NSCLC) with malignant pleural effusion detected at thoracotomy. They concluded that tumor resection was not beneficial for survival of these patients. This conclusion could discourage, and even contraindicate any attempt at resection. However, in their series, 5-year survivors were observed when either complete or incomplete resections were performed. From 1984 to 1999, we operated on 38 patients for NSCLC whose preoperative workup did not disclose any contraindication in our department. At thoracotomy, we were surprised to discover macroscopic pleural dissemination. The thoracotomy remained exploratory in 20 patients (survival: median, 13 months; 5 years, 0%). A lung resection with pleurectomy and mediastinal lymph node dissection was performed in 18 patients (survival: median, 31 months; 5 years, 21%). The difference in survival was significant (p ⫽ 0.009) between groups. In a multicentric study, Ichinose and colleagues [2] reported similar results (collected cases n ⫽ 227). According to Ohta and associates [3], a limited operation for local control in such patients is sufficient. We also observed this in our small series: median survival after pneumonectomy (n ⫽ 5), 24 months and after lobectomy (n ⫽ 13), 33 months. Pleural dissemination in the absence of other metastatic disease is probably a particular entity that resembles pleural cavity seeding due to visceral pleural involvement [4], or possibly a latter stage. The NSCLC pleural dissemination is an interesting topic deserving much more consideration. Operation must not be discouraged. Few articles deal with this subject. Reyes and colleagues [5], who were among the first to report success after operation, demonstrated the correct course when they pointed out that the most logical therapeutic approach is neoadjuvant chemotherapy. At the end of their article, Sawabata and colleagues [1] suggest a trial of multimodality treatment for patients with NSCLC with malignant effusion. We believe trials are not only warranted but necessary because they may offer a chance of cure. This does not apply only to unsuspected malignancy discovered at thoracotomy, but should encompass other NSCLC with pleural effusion. This requires suitable patient selection for such trials and the need to convince physicians and oncologists of the possibility of adjuvant operation and not just drainage of the pleural effusion with or without pleurodesis with sclerosing agents. Marc Riquet, PhD, MD Christophe Foucault, MD Franc¸ ois Souilamas, MD Service de Chirurgie Thoracique Hoˆ pital Europe´ en Georges Pompidou 75015 Paris, France e-mail: [email protected]
References 1. Sawabata N, Matsumura A, Motohiro A, et al. Malignant minor pleural effusion detected on thoracotomy for patients with non-small cell lung cancer: is tumor resection beneficial for prognosis? Ann Thorac Surg 2002;73:412–5. 2. Ichinose Y, Tsuchiya R, Koike T, et al. The prognosis of patients with non-small cell lung cancer found to have carcinomatous pleuritis at thoracotomy. Surg Today 2000;30:1062–6. © 2002 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 2002;74:1747–50
3. Ohta Y, Tanaka Y, Hara T, et al. Clinicopathological and biological assessment of lung cancers with pleural dissemination. Ann Thorac Surg 2002;69:1025–9. 4. Manac’h D, Riquet M, Medioni J, et al. Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor. Ann Thorac Surg 2001;71:1088 –93. 5. Reyes L, Parvez Z, Regal AM, Takita H. Neoadjuvant chemotherapy and operations in the treatment of lung cancer with pleural effusion (letter). J Thorac Cardiovasc Surg 1991;101:946–7.
Reply To the Editor: I read a response from Riquet and colleagues to our article [1], which reported operation for non-small cell lung cancer (NSCLC) with malignant minor pleural effusion detected at thoracotomy. They pointed out that the 5-year survival rate for patients with pleural involvement was approximately 20% in other studies [2, 3], and that operation should not be discouraged. However, the number of patients who underwent adjuvant therapy was high in these studies. The reason why our completely resected group of patients had a poor survival rate may be due not only to no adjuvant therapy but also a high rate of p1 or p2, which often is associated with a high rate of malignant pleural effusion. Malignant cells in the pleural effusion may arrive from the visceral pleura above a NSCLC. Tumor cells are detected on the pleura above a NSCLC in 20% to 30% of patients [4, 5]. Therefore, it is very difficult to distinguish frank malignant effusion from a contaminated effusion. Although pleural involvement is a poor prognostic factor [6], survival rate may be different between contaminated and primary pleural effusions. Notwithstanding contaminated or primary effusions, malignant pleural effusion indicates a poor prognosis. However, I believe that operation for NSCLC with malignant pleural effusion should not be discouraged but should be tried with adjuvant or induction therapy. Trials of multimordality treatment may offer a good chance of survival in patients with NSCLC with pleural involvement alone and no distant metastasis. Noriyoshi Sawabata, MD Division of Surgery Toneyama National Hospital 5-1-1 Toneyama, Toyonaka, Osaka 560-8552, Japan e-mail: [email protected]
References 1. Sawabata N, Matsumura A, Motohiro A, et al. Malignant minor pleural effusion detected on thoracotomy for patients with non-small cell lung cancer: is tumor resection beneficial for prognosis? Ann Thorac Surg 2002;73:412–5. 2. Ichinose Y, Tsuchiya R, Koike T, et al. The prognosis of patients with non-small cell lung cancer found to have carcinomatous pleuritis at thoracotomy. Surg Today 2000;30:1062–6. 3. Ohta Y, Tanaka Y, Hara T, et al. Clinicopathological and biological assessment of lung cancers with pleural dissemination. Ann Thorac Surg 2000;69:1025–9. 4. Ichinose Y, Yano T, Asoh H, Yokoyama H, Fukuyama Y, Katsuda Y. Diagnosis of visceral pleural invasion in resected lung cancer using a jet stream of saline solution. Ann Thorac Surg 1997;64:1626 –9. 5. Sawabata N, Ohta M, Maeda H. Fine-needle aspiration cytologic technique for lung cancer has a high potential of malignant cell spread through the tract. Chest 2000;118:936 –9. 6. Manac’h D, Riquet M, Medioni J, et al. Visceral pleura invasion by non-small cell lung cancer: an underrated bad prognostic factor. Ann Thorac Surg 2001;71:1088 –93. 0003-4975/02/$22.00