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Eur J Cardiothorac Surg 2002;22:1039-1040
© 2002 Elsevier Science NL
Letter to the Editor |
Department of Radiotherapy, Technical University of Munich, Klinikum rechts der Isar, Ismaninger Strasse 22, Munich D-81675, Germany
Received 29 July 2002; accepted 17 September 2002.
* Tel.: +49-89-4140-4512; fax: +49-89-4140-4882
e-mail: bjeremic{at}lrz.tu-muenchen.de
Key Words: Second primary cancer • Non-small-cell lung cancer • Radiation therapy
I read with interest the article by Aziz et al. [1] about the management of 51 second primary lung cancers, of whom 41 were metachronous second primary non-small-cell lung cancer (mspNSCLC). While surgery is the treatment of choice for majority of patients with both initial and second metachrounous primary early stage NSCLC, there is a subgroup of patients that never undergo surgery for the initial early NSCLC due to severe comorbidities (mostly cardiopulmonary), age, or refusal. For this patient population radiation therapy (RT) is the treatment of choice over the years. With high-dose RT it is possible to obtain 5-year survivals of 25–30% in clinical stages I and II [2,3].
We have recently pioneered an investigation of the occurrence of various second metachronous cancers in long-term survivors of early (clinical stages I and II) NSCLC after RT alone, including a mspNSCLC [4]. Using the same criteria as Aziz et al. [1] did with slightly more intensive follow-up schedule (patients were followed at intervals of 2–3 months during first 2 years, 4–6 months intervals during years 3–4 and at 6–12 months intervals thereafter), we have shown that they occur at approximately the same rate as in surgical series. Of 26 such cases (out of a total of 194 patients), nine were mspNSCLC (six clinical stage I and three stage II) [4]. For them, the cumulative incidence was 6.0% (SE, 2.8%) at 5 years and 14.2% (SE, 5.2%) at 10 years. The rate of developing mspNSCLC per patient per year was 1.4% (CI, 0.5–2.3%), with the rates of developing second smpNSCLC during the first and second 5-year period post-RT (0–5 and 5–10 years) being 1.0% (CI, 0.1–1.9%) and 2.2% (CI, 0–4.6%), respectively. For these patients, a second course of RT alone was effective treatment option. The overall survival at 5 years was 30% and the cause-specific survival rates were 100% at 1 year, 80% at 2 years and 53% at 3–5 years. With the use of high-dose local conventionally fractionated or hyperfractionated RT which may be interpreted as the radiotherapeutic ‘equivalent’ to limited surgical resection these results, although retrospective, coming from a single institution, and reporting on a few patients, show that RT is a effective treatment modality alternative to surgery in cases of second NSCLC occurring in this patient population, notorious of having an excess of cancer-unrelated deaths.
Regardless of the treatment (surgery or RT), patients with early stage NSCLC are at a constant risk of developing second cancer. This risk increases with time, and I can do nothing but completely agree with Aziz et al. [1] about the necessity of close surveillance in this patient population. It may also enable early diagnosis of isolated intrathoracic recurrences, among which those located at bronchial stump may be suitable for more aggressive treatment approach. As we have successfully shown, with high-dose RT in patients with isolated bronchial stump recurrences satisfactory results may be obtained such as the median survival time of approximately 36 months and a 5-year survival rates of approximately 30% [5].
References
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