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Response to issues raised by Dr. Debevec “Is postoperative radiotherapy for radically resected NSCLC detrimental and therefore unnecessary?”
Lung Cancer (2004) 46, 381
LETTER TO THE EDITOR
Response to issues raised by Dr. Debevec ‘‘Is postoperative radiotherapy for radically resected NSCLC detrimental and therefore unnecessary?’’ First of all, we would like to thank Dr. Debevec for clarifications, comments and insights in his recent Letter to the Editor. In reading published studies, it is often difficult to interpret details which are not explicitly stated. While it was implied in the Debevec et al. report [1] that complete resections were carried out by virtue of the use of the phrase ‘‘radically resected N2’’, a reader cannot assume this fact unless it is explicitly stated that R0 resections were in fact performed. This is true even though the radicalism of surgery was assessed by both the surgeon and pathologist. Further to this point, the paper concedes on p. 105 that it is inherently difficult to assess contralateral nodes at the time of surgery and hence N3 disease may not have been identified. In addition, Debevec et al. notes that there were more left lower lobe tumours in the adjuvant radiation arm and interestingly, there were more locoregional recurrences as the first site of recurrence despite adjuvant radiation. This finding may lead one to assume that the resection was not complete. However, in light of this clarification by the authors, we intend to modify our description of this trial in Appendix A of our guideline [2]. We agree with Dr. Debevec that postoperative radiotherapy in radically resected stage I and II NSCLC patients is not routinely indicated. It is the prac-
tice at our institutions not to recommend thoracic irradiation in this setting. Further scientific evidence for or against a particular therapeutic option is always desirable. However, with many studies now investigating the use of chemoprevention and adjuvant chemotherapy, protocols investigating adjuvant thoracic irradiation will be difficult to institute even with the current high prevalence of lung cancer. Recent intergroup trials attempting to address this issue had to be prematurely closed due to lack of accrual. Therefore, the question of the role of postoperative irradiation in surgically resected stage III NSCLC will remain unresolved.
References [1] Debevec M, Bitenc M, Vidmar S, et al. Postoperative radiotherapy for radically resected N2 non-small-cell lung cancer (NSCLC): randomized clinical study 1988—1992. Lung Cancer 1996;14:99—107. [2] Okawara G, Ung YC, Markman BR, MacKay JA, Evans WK. Postoperative radiotherapy in stage II or IIIA completely resected non-small cell lung cancer: a systematic review and practice guideline. Lung Cancer 2004;44:1— 11.
0169-5002/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2004.06.001
G. Okawara 699 Concession Street, Hamilton Ont., Canada L8M-5C2 Tel.: +1 9055756326 6 May 2004
LETTER TO THE EDITOR
Response to issues raised by Dr. Debevec ‘‘Is postoperative radiotherapy for radically resected NSCLC detrimental and therefore unnecessary?’’ First of all, we would like to thank Dr. Debevec for clarifications, comments and insights in his recent Letter to the Editor. In reading published studies, it is often difficult to interpret details which are not explicitly stated. While it was implied in the Debevec et al. report [1] that complete resections were carried out by virtue of the use of the phrase ‘‘radically resected N2’’, a reader cannot assume this fact unless it is explicitly stated that R0 resections were in fact performed. This is true even though the radicalism of surgery was assessed by both the surgeon and pathologist. Further to this point, the paper concedes on p. 105 that it is inherently difficult to assess contralateral nodes at the time of surgery and hence N3 disease may not have been identified. In addition, Debevec et al. notes that there were more left lower lobe tumours in the adjuvant radiation arm and interestingly, there were more locoregional recurrences as the first site of recurrence despite adjuvant radiation. This finding may lead one to assume that the resection was not complete. However, in light of this clarification by the authors, we intend to modify our description of this trial in Appendix A of our guideline [2]. We agree with Dr. Debevec that postoperative radiotherapy in radically resected stage I and II NSCLC patients is not routinely indicated. It is the prac-
tice at our institutions not to recommend thoracic irradiation in this setting. Further scientific evidence for or against a particular therapeutic option is always desirable. However, with many studies now investigating the use of chemoprevention and adjuvant chemotherapy, protocols investigating adjuvant thoracic irradiation will be difficult to institute even with the current high prevalence of lung cancer. Recent intergroup trials attempting to address this issue had to be prematurely closed due to lack of accrual. Therefore, the question of the role of postoperative irradiation in surgically resected stage III NSCLC will remain unresolved.
References [1] Debevec M, Bitenc M, Vidmar S, et al. Postoperative radiotherapy for radically resected N2 non-small-cell lung cancer (NSCLC): randomized clinical study 1988—1992. Lung Cancer 1996;14:99—107. [2] Okawara G, Ung YC, Markman BR, MacKay JA, Evans WK. Postoperative radiotherapy in stage II or IIIA completely resected non-small cell lung cancer: a systematic review and practice guideline. Lung Cancer 2004;44:1— 11.
0169-5002/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.lungcan.2004.06.001
G. Okawara 699 Concession Street, Hamilton Ont., Canada L8M-5C2 Tel.: +1 9055756326 6 May 2004