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Eur J Cardiothorac Surg 2003;23:1077-1078
© 2003 Elsevier Science NL
Letter to the Editor |
Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai 400012, India
Received 14 February 2003; accepted 17 March 2003.
* Corresponding author. Tel.: +91-22-24177000; fax: +91-22-24146937
e-mail: cspramesh{at}vsnl.net
Key Words: Trachea • Cancer • Margins • Postoperative radiotherapy
We read with interest the article by Hazama et al. [1] on a retrospective analysis of 20 cases of primary tracheal cancer. We take exception to the recommendation that tension reduction should take precedence over surgical margins during tracheal resections for cancer and the implied suggestion that postoperative radiotherapy is expendable in many cases, even with positive margins. Though we agree that anastomotic tension is disastrous and should be avoided, implying that resection margins can be compromised is a dangerous suggestion. The authors base their conclusion on the fact that none of their five patients with positive resection margins recurred locally, though only three of these patients received postoperative radiotherapy. We believe that five patients are too few to base such a dramatic recommendation on. It is also to be noted that all these five patients had adenoid cystic carcinoma, which has better biological behaviour than other tracheal cancers. It is well known that margin positivity in adenoid cystic carcinoma is far less sinister than in squamous carcinomas [2]. In Grillo's series, four of the five patients with positive invasive margins in squamous carcinomas of the trachea died of the disease. Extrapolating the results of five patients with adenoid cystic carcinoma to all tracheal cancers is naïve at best and dangerous at worst. Grillo has conclusively proven that tracheal resections as long as 6.5 cm can be safely performed by adequate pretracheal mobilization, right hilar mobilization and cervical flexion [3]. As seen in the authors' own series (mean length, 4.0 cm, range, 2.5–4.8 cm), it is very rare that more extensive resections are required. Extensive tracheal reconstructions, when necessary, need to be performed in centers specializing in this type of surgery.
Both squamous and adenoid cystic carcinomas are sensitive to radiotherapy and it appears unwise to withhold postoperative radiotherapy in these patients. As noted by the authors themselves and by others [2], margins obtained at tracheal resections are usually narrow and routine postoperative radiotherapy is advisable, even in patients with negative surgical margins and negative lymph nodes [2]. There have not been (and probably will not be, given the rarity of the disease) any randomized trials to assess the value of adjuvant radiotherapy, but consolidating one local treatment (surgery) with another (radiotherapy) seems logical in a disease where the consequences of local recurrence are uniformly fatal. We therefore disagree with the authors on two counts – firstly, that serious effort needs to be made to achieve negative resection margins, especially in squamous carcinomas and secondly, that postoperative radiotherapy should be recommended routinely to all patients.
References
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