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Eur J Cardiothorac Surg 2007;31:717-718. doi:10.1016/j.ejcts.2007.01.030
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
a Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, United States
b Department of Epidemiology, UAB School of Public Health, Birmingham, AL, United States
* Address: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd., THT 712, Birmingham, AL 35294, United States. Tel.: +1 205 934 5937; fax: +1 205 934 6218. (Email: rcerfolio{at}uab.edu).
Dr Venuta and colleagues have provided a well written and important report on their fourteen year experience of pulmonary resection in patients with non-small cell lung cancer who have received neo-adjuvant chemo or chemo-radiotherapy [1]. The main import from this retrospective study is that lobectomy can be performed safely after neoadjuvant chemo-radiotherapy in experienced hands. Several previous articles have also supported this finding. The importance of muscle flaps or pedicled flaps to protect the bronchus, although not mentioned in this article cannot be underestimated. Thus, the only controversy presented is the risk of pneumonectomy after induction chemotherapy or concomitant chemo-radiotherapy.
The most striking finding from Dr Venuta's study is that four of the five operative deaths occurred in patients who underwent pneumonectomy. First, this means that only one of the 106 patients who underwent lobectomy experienced an operative mortality. This fantastic result lauds the outstanding technical expertise of Dr Venuta and his surgical colleagues, since lobectomy after preoperative therapy is often a more technically demanding operations than pneumonectomy. In addition, the authors show that sleeve resection of the artery as well as the bronchus can be safely performed in a highly irradiated and/or chemotherapized field. These findings have been corroborated by us as well as by others.
However, the fact that 80% of those patients who died had a pneumonectomy raises a red flag – but for what? Is the warning to avoid pneumonectomy after radiation and chemotherapy or is it to avoid pneumonectomy after chemotherapy alone? We are not told if these patients who died after pneumonectomy underwent radiation or just chemotherapy. Nor are we told how many of the 28 patients who were operative survivors after pneumonectomy had radio-chemotherapy or chemotherapy alone. My suspicion is that most of these patients had combined neoadjuvant chemo-radiotherapy since their tumors were large enough to require pneumonectomy. And if this assumption is true, then perhaps the take home message ought to be to avoid radiation when pneumonectomy is known to be required in a patient with biopsy proven N2 disease. This statement itself raises several other controversial questions. Can one really know when a pneumonectomy is needed? Is one obliged to resect all disease that was initially present prior to neoadjuvant therapy or can one perform a smaller and a less risky resection, i.e. a sleeve resection, if the patient has had a favorable oncologic response to their preoperative therapy. We favor the removal of all tissue that initially was involved with cancer. This is why we still encourage resection for patients with non-small cell cancer as well as those with esophageal cancer who appear to be complete responders after repeat PET scanning.
What are the author's recommendations? Do they recommend resection of all disease that was initially present? For example, if the proximal and distal right main stem were involved with cancer in a patient who has pathologic N2 disease, does that patient have to have a pneumonectomy even if his post-adjuvant bronchoscopy shows complete resolution of the distal main stem disease making a sleeve resection now possible with negative margins? Can he have a bronchial sleeve resection and if so are frozen sections reliable to ensure no cancer will return at the anastomotic margins on follow-up? Do the authors recommend preoperative chemo alone in a patient who is suspected to require a pneumonectomy and avoid the addition of radiation as we have come to prefer over the past five years? In 2005 we described our experience and concluded that it is best to avoid preoperative radiation and use chemotherapy alone in patients that we thought to require pneumonectomy [2].
Finally, Dr Venuta's outstanding paper has a large number of patients who had N3 disease. Assuming all patients had biopsy proven N3 disease initially, how do the authors prove the N3 disease has resolved prior to resection if it was below the clavicle initially? Do they think an N3 nodes can be cleared on mere clinically grounds by the percent decrease in the maximum standardized uptake values of the lymph nodes as shown by repeat PET scanning or by its decrease in size on repeat CT scanning? Do they instead require repeat biopsy as we have tried to do using repeat EUS-FNBA or EBUS? We are told that ‘repeat mediastinoscopy after induction was not routinely performed’. Stage IIIB from N3 disease is a different disease and if the authors do not used these techniques to pathologically prove that the N3 lymph node has been down-staged (eradicated or sterilized) after neoadjuvant therapy and since the initially involved node cannot be resected or biopsied at the time of thoracotomy how are these patients selected for resection? I congratulate Dr Venuta and his colleagues in another important manuscript that chronicles their technical expertise.
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