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Eur J Cardiothorac Surg 2006;30:686-687
© 2006 Elsevier Science NL
Letters to the Editor |
Herz-, Thorax-, und herznahe Gefäßchirurgie, Klinikum der Universität Regensburg, Franz-Josef-Strauss-Allee 11, 93055 Regensburg, Germany
Received 27 June 2006; accepted 29 June 2006.
* Corresponding author. Tel.: +49 9406 284535; fax: +49 9406 284400. (Email: KarstenWiebe{at}t-online.de).
Key Words: Extended pulmonary resection • Locally advanced NSCLC • T4 non-small cell lung cancer • Cardiopulmonary bypass
The main concern of Zielinski and Kuzdzal [1] is a crucial issue. Due to a lack of evidence there is no firm guideline for the surgical treatment of T4 non-small cell lung cancer (NSCLC) [2]. The authors conclude their comment by accepting that the therapy remains highly controversial. As outlined by Grunwald [3] and others, stage IIIB carcinomas, which in general are not considered for surgical therapy, should better be divided into groups with extensive lymphogenic spread (N3) and with advanced local tumor invasion (T4). For T4 N0 disease, aggressive surgical treatment within a multimodality therapy has been advocated and is strongly recommended by us, even when the application of cardiopulmonary bypass is required. As indicated by the small number of NSCLC patients included in the retrospective study, we were restrictive in performing radical surgical procedures in T4 NSCLC [4]. Our results underline this strategy. Three patients, presenting with T4 NSCLC tumors, successfully underwent radical surgical approaches and died within months due to distant metastatic disease despite neoadjuvant chemotherapy (n = 1) and adjuvant radiochemotherapy (n = 2). On final histopathological evaluation, all cases had positive N1 or N2 nodes. We found in one patient, that preoperative staging including mediastinoscopy failed to show N2 nodal involvement. Thus, from the poor long-term outcome in this small group we learned, that NSCLC tumors with nodal disease infiltrating the heart or great vessels do not really profit from an aggressive surgical procedure. In case of N2 or N3 nodal involvement, extended surgical procedures with circulatory support for T4 tumors should not be offered.
The role of neoadjuvant treatment in this setting is not very well characterized. From reported data and our own experience, we feel that for T4 NSCLC tumors undergoing extended resection neoadjuvant therapy and subsequent restaging seems to be beneficial [5]. However, in extended pneumonectomies a significantly elevated perioperative risk following chemotherapy may be associated with such a strategy.
We and others demonstrated that the application of cardiopulmonary bypass for extended pulmonary resections is feasible and safe. Clearly, advanced sarcomas profit from a radical surgical approach with cardiopulmonary bypass. The importance of patient selection for a successful outcome in case of NSCLC disease has been stressed in the editorial comment for the discussed paper [4]. With increasing reports on surgical treatments of T4 NSCLC tumors, we hope that the indication for radical surgical therapy in the future may be defined more precisely, allowing replacement of the unspecific description ‘in carefully selected patients’.
References
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