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Management of Air Leaks
CORRESPONDENCE
Management of Air Leaks
size and 100% five-year survival with 5 peripherally located lung cancers. Steele and Buell [lo] To the Editor: documented a 57% five-year survival rate in the With respect to Dr. John C. McCabe's correspon- Cooperative Veterans Administration and Armed dence (Ann Thorac Surg 21:259, 1976) commenting Forces Hospital Study with lung cancers under 2 cm in on Dr. Kirsh's discussion of prolonged air leak (Ann size. Survival fell to 41% for 2.5 to 4 cm lesions and to Thorac Surg 20:215, 1975), I believe Dr. McCabe 31% for those4.5 to 6 cm in size [lo]. Two centimeters missed the point Dr. Kirsh was making in the article. thus appears to be a critical dividing line with regard It was a collective review rather than a specific es- to prognosis. We recently reviewed our experience with 19 papousal of pneumoperitoneum. Moreover, I believe that many thoracic surgeons would consider Dr. tients treated by resection over the past twenty years McCabe's recommendation of tolerating an air leak for primary lung cancers of an average diameter under for up to 21 days radical, with a definite risk of pro- 2 cm. Survival to the present time is 89.5% (17 of the ducing empyema. The use of induced pneumo- 19). Of the 12 patients followed for five years, 10 (83%) peritoneum, either intraoperatively through the survived. The 2 patients who have died had lesions diaphragm or transabdominally, as was practiced 2.7 and 3.2 cm in size [8, 91. Admittedly, the references cited show a wide and frequently in collapse therapy, by thoracic surgeons of an earlier generation, is quite safe. It certainly has not readily explainable variability in five-year been found to shorten the duration of air leaks, reduce survival-from 57 to 83% for small primary lung the attendant morbidity of indwelling pleural tubes, cancers-and focus upon a small proportion of lung cancer patients. Nevertheless, these clearly represent and thus decrease the length of hospitalization. the best lung cancer survival figures, thereby emphasizing the importance of tumor size in relation to John S . McCabe, M . D . prognosis and raising the question whether the overMercy Hospital all poor results of resection for lung cancer could be 1501 Pride 6 Locust Sts improved if we could detect the tumors earlier. Pittsburgh, PA 15219 There is no doubt that lung cancer connotes a grim outlook for most patients. However, these studies show a progressive improvement in long-term surviLung Cancer Size and Prognosis val of patients with smaller lesions. This fact-the To the Editor: central message of this letter-is not sufficiently recThe excellent and thoughtful article by Kirsh and as- ognized. Pervasive pessimism and the theory of sociates, "Carcinoma of the Lung: Results of Treat- biological predeterminism with regard to lung cancer ment over Ten Years" (Ann Thorac Surg 21:371,1976), are most certainly incorrect concepts and can lead to a contained an error of fact concerning the relationship dangerous and unwarranted laissez-faire attitude. of survival to size of the primary lung cancer that we Recent success with new screening projects may help think is most important to correct for both practical promote wider efforts at early diagnosis [l,2, 4, 61. and philosophical reasons. It is our firm belief that the size of a lung tumor is a The authors state, "Despite widespread effort and prime, if notthe prime, determinant of survival. In the communication on the subject, there is still no uni- future, innovative methods to detect lung cancer at an formity of opinion concerning what factors influence earlier stage might improve the overall poor results of long-term survival following pulmonary resection for operation, which are attributable in large part to the bronchogenic carcinoma. No difference has been advanced size, and therefore late stage, of most prifound between survivors and nonsurvivors when mary lung cancers being diagnosed and treated. comparing the size of the primary lesion . . ." We believe this last statement is incorrect, because small Jefferson F . Ray, I l l , M . D . lung cancers, although detected much less frequently Ben R . Lawton, M . D . than larger ones, have been shown to yield very dif- William 0 . Myers, M . D . ferent and considerably better survival rates after re- Richard D . Sautter, M . D . section. Marshfield Clinic and Marshfield A 70% five-year survival has been attained in 48 Medical Foundation patients-with lung cancers under 2 cm in size treated Marshfield, Wl 54449 at the Mayo Clinic [5], and the Mayo group has achieved similar results with in situ lung tumors [ll]. Delarue and colleagues [3] also reported 70% survival with small primary lung cancers [31. Overholt [7] has References 1. Baker RR, Marsh BR, Frost JK, et al: The detection achieved 66% survival with small primary lung cancers. Yashar and Yashar [121 had a 61% five-year surand treatment of early lung cancer. Ann Surg vival rate with 18 primary lung cancers under 2 cm in 179:813, 1974
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Management of Air Leaks
size and 100% five-year survival with 5 peripherally located lung cancers. Steele and Buell [lo] To the Editor: documented a 57% five-year survival rate in the With respect to Dr. John C. McCabe's correspon- Cooperative Veterans Administration and Armed dence (Ann Thorac Surg 21:259, 1976) commenting Forces Hospital Study with lung cancers under 2 cm in on Dr. Kirsh's discussion of prolonged air leak (Ann size. Survival fell to 41% for 2.5 to 4 cm lesions and to Thorac Surg 20:215, 1975), I believe Dr. McCabe 31% for those4.5 to 6 cm in size [lo]. Two centimeters missed the point Dr. Kirsh was making in the article. thus appears to be a critical dividing line with regard It was a collective review rather than a specific es- to prognosis. We recently reviewed our experience with 19 papousal of pneumoperitoneum. Moreover, I believe that many thoracic surgeons would consider Dr. tients treated by resection over the past twenty years McCabe's recommendation of tolerating an air leak for primary lung cancers of an average diameter under for up to 21 days radical, with a definite risk of pro- 2 cm. Survival to the present time is 89.5% (17 of the ducing empyema. The use of induced pneumo- 19). Of the 12 patients followed for five years, 10 (83%) peritoneum, either intraoperatively through the survived. The 2 patients who have died had lesions diaphragm or transabdominally, as was practiced 2.7 and 3.2 cm in size [8, 91. Admittedly, the references cited show a wide and frequently in collapse therapy, by thoracic surgeons of an earlier generation, is quite safe. It certainly has not readily explainable variability in five-year been found to shorten the duration of air leaks, reduce survival-from 57 to 83% for small primary lung the attendant morbidity of indwelling pleural tubes, cancers-and focus upon a small proportion of lung cancer patients. Nevertheless, these clearly represent and thus decrease the length of hospitalization. the best lung cancer survival figures, thereby emphasizing the importance of tumor size in relation to John S . McCabe, M . D . prognosis and raising the question whether the overMercy Hospital all poor results of resection for lung cancer could be 1501 Pride 6 Locust Sts improved if we could detect the tumors earlier. Pittsburgh, PA 15219 There is no doubt that lung cancer connotes a grim outlook for most patients. However, these studies show a progressive improvement in long-term surviLung Cancer Size and Prognosis val of patients with smaller lesions. This fact-the To the Editor: central message of this letter-is not sufficiently recThe excellent and thoughtful article by Kirsh and as- ognized. Pervasive pessimism and the theory of sociates, "Carcinoma of the Lung: Results of Treat- biological predeterminism with regard to lung cancer ment over Ten Years" (Ann Thorac Surg 21:371,1976), are most certainly incorrect concepts and can lead to a contained an error of fact concerning the relationship dangerous and unwarranted laissez-faire attitude. of survival to size of the primary lung cancer that we Recent success with new screening projects may help think is most important to correct for both practical promote wider efforts at early diagnosis [l,2, 4, 61. and philosophical reasons. It is our firm belief that the size of a lung tumor is a The authors state, "Despite widespread effort and prime, if notthe prime, determinant of survival. In the communication on the subject, there is still no uni- future, innovative methods to detect lung cancer at an formity of opinion concerning what factors influence earlier stage might improve the overall poor results of long-term survival following pulmonary resection for operation, which are attributable in large part to the bronchogenic carcinoma. No difference has been advanced size, and therefore late stage, of most prifound between survivors and nonsurvivors when mary lung cancers being diagnosed and treated. comparing the size of the primary lesion . . ." We believe this last statement is incorrect, because small Jefferson F . Ray, I l l , M . D . lung cancers, although detected much less frequently Ben R . Lawton, M . D . than larger ones, have been shown to yield very dif- William 0 . Myers, M . D . ferent and considerably better survival rates after re- Richard D . Sautter, M . D . section. Marshfield Clinic and Marshfield A 70% five-year survival has been attained in 48 Medical Foundation patients-with lung cancers under 2 cm in size treated Marshfield, Wl 54449 at the Mayo Clinic [5], and the Mayo group has achieved similar results with in situ lung tumors [ll]. Delarue and colleagues [3] also reported 70% survival with small primary lung cancers [31. Overholt [7] has References 1. Baker RR, Marsh BR, Frost JK, et al: The detection achieved 66% survival with small primary lung cancers. Yashar and Yashar [121 had a 61% five-year surand treatment of early lung cancer. Ann Surg vival rate with 18 primary lung cancers under 2 cm in 179:813, 1974
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