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Eur J Cardiothorac Surg 2003;23:256
© 2003 Elsevier Science NL
Letter to the Editor |
Division of General Thoracic Surgery, Department of Surgical Sciences, Catholic University, Largo A. Gemelli 1, 00168 Rome, Italy
Received 1 October 2002; received in revised form 4 November 2002; accepted 4 November 2002.
* Corresponding author. Tel.: +39-335-836-6161; fax: +39-06-305-1162
e-mail: alfcesario{at}yahoo.com
Key Words: Neoadjuvant chemotherapy • Chemoradiotherapy • Mediastinoscopy
In the year 2001, following an interesting comment by Daniels et al. [1] we have discussed the issue of routine mediastinoscopy in the intrathoracic clinical staging of non small cell lung cancer (NSCLC) patients in opposition with those colleagues who suggested that mediastinoscopy should be performed in every case of NSCLC patients where surgery was indicated [2]. Put briefly, we objected that routinely adopting mediastinoscopy represented a compromise and that it should be reserved to those patients who, upon a CT scan suspect of mediastinal (N2) involvement, are to be enrolled in an induction therapy protocol.
Very recently, in a concise report of their experience, Dujon et al. [3] substantially confirmed this point of view on the basis of the fact that upon 1670 cNO patients who underwent pulmonary resection plus mediastinal lymphadenectomy, only 166 proved to have mediastinal involvement at the definitive histology assessment (so called ‘pathologic’: p-N2). Of these patients only 83 (4.9%) were probably susceptible of a preoperative diagnosis of the N2 involvement (stations 2R, 4R and 4L) by cervical mediastinoscopy, in the most optimistic view in terms of a supposed 100% accuracy of the procedure. On these premises Dijon continues, stating that "since we operated all N2 appearing resectable according to CT scan, we do not understand the role mediastinoscopy can play in discriminating operability and resectability..." and reported a 5-year survival rate for 378 cN2 patients, surgically resected, of 26.8% (overall) and 32.9% (minimal pN2 cases). The scope of this short, friendly letter, is to briefly comment these figures.
The reported evidence clearly demonstrates that the Authors do not adopt any induction therapy approach in cN2 patients where technical feasibility of a complete resection is believed possible on the basis of the CT scan findings only. In this view, a contradictory statement is made in the conclusive paragraph "we believe mediastinoscopy is useful...to ensure the diagnosis of N2 or N0 disease (in case of suspected macroscopic N2) before neoadjuvant chemo and/or radiation therapy in order to ensure efficacy of treatment".
Their clinical behavior seems to be in opposition to their ‘credo’.
Could the Authors clarify their attitude? Do they perform mediastinoscopy only in cN2 patients where resectability is supposed impossible? Do they think the treatment of cN2 NSCLCs is only a matter of resectability rather than resectability and operability? Could they discuss the potential role of induction therapy in their experience?
We can conclude this brief communication by simply asserting that, to date, the state of the art regarding the process of intrathoracic staging in NSCLC remains not yet reached and a consensus toward an homogeneous approach is urgently needed.
References
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