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Eur J Cardiothorac Surg 2007;32:550. doi:10.1016/j.ejcts.2007.06.030
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Operative risk of pneumonectomy after induction chemoradiotherapy

Department of Thoracic and Vascular Surgery, University of Antwerp, Antwerp, Belgium

Received 27 February 2007; accepted 24 June 2007.

^_* Corresponding author. Address: Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Wilrijkstraat 10, B-2650 Edegem (Antwerp), Belgium. Tel.: +32 3 8214360; fax: +32 3 8214396. (Email: paul.van.schil{at}uza.be).

Key Words: Lung cancer • Induction therapy • Surgery • Pneumonectomy • Chemotherapy • Radiotherapy

I read with great interest the recent manuscript by Mansour et al. discussing the risk of pneumonectomy after induction chemotherapy [1]. The authors nicely demonstrate that pneumonectomy can be performed safely after induction chemotherapy. However, there might be a difference when chemotherapy is combined with radiotherapy as induction treatment, a topic that was not addressed by the authors in the discussion.

In two large, recently completed, phase III randomized trials including patients with stage IIIA-N2 non-small cell lung cancer, results regarding operative mortality of pneumonectomy were quite different and this may be related to the type of induction therapy.

In the EORTC 08941 phase III trial, patients with proven stage IIIA-N2 disease were randomized between surgery and radiotherapy after a response to induction chemotherapy [2–3]. There was no difference in overall and progression-free survival between both arms.

In the Intergroup 0139 trial, patients with proven stage IIIA-N2 NSCLC were randomized between induction chemoradiotherapy followed by surgery and a full course of chemoradiotherapy [4–5]. There was no difference in overall survival between both arms, but there was a significant difference in progression-free survival favoring the surgical arm.

Operative mortality of patients undergoing lobectomy was not different, being 1% in the Intergroup trial, and 0% in the EORTC trial [2,5]. However, there was a striking difference in operative mortality after pneumonectomy, being 26% in the Intergroup trial, and 6.9% in the EORTC trial. Analyzing left and right pneumonectomies the differences were even more pronounced; in the EORTC trial, a left pneumonectomy had a mortality of 9.1% and a right one 5.3% [2]. For the Intergroup trial, mortality rates for left simple, left complex, right simple and right complex pneumonectomies were 0, 16, 29 and 50%, respectively [4,5]. Although a direct comparison of both studies is not possible, the type of induction therapy – chemotherapy only versus chemoradiotherapy – might be important in explaining the observed mortality differences.

Unfortunately, there are no large, published randomized studies directly comparing induction chemotherapy versus chemoradiotherapy and outcome of lobectomy and pneumonectomy. So, even when pneumonectomy can be safely performed after induction chemotherapy, caution should be exerted in performing a pneumonectomy after induction chemoradiotherapy, especially on the right side when a complex procedure has to be performed.

Footnotes

^\#9734; The authors of the original paper [1] were invited to reply to this Letter to the Editor but their reply was not received.

References

1. Mansour Z, Kochetkova EA, Ducrocq X, Vasilescu, MD, Maxant G, Buggenhout A, Wihlm JM, Massard G. Induction chemotherapy does not increase the operative risk of pneumonectomy!. Eur J Cardiothorac Surg 2007;31:181-185.[Abstract/Free Full Text]
2. Van Schil P, Van Meerbeeck J, Kramer G, Splinter T, Legrand C, Giaccone G, Manegold C, van Zandwijk N. Morbidity and mortality in the surgery arm of EORTC 08941 trial. Eur Resp J 2005;26:192-197.[Abstract/Free Full Text]
3. Van Meerbeeck J, Kramer G, Van Schil P, Legrand C, Smit E, Schramel F, Tjan-Heijnen V, Biesma B, Debruyne Ch, van Zandwijk N, Splinter T, Giaccone G, on behalf of the EORTC Lung Cancer Group. Randomised controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-small cell lung cancer. J Natl Cancer Inst, 2007;99:442–50.
4. Albain KS, Swann RS, Rusch VR, Turrisi AT, Shepherd FA, Smith CJ, Gandara DR, Johnson DH, Green MR, Miller RC. Phase III study of concurrent chemotherapy and radiotherapy (CT/RT) versus CT/RT followed by surgical resection for stage IIIA-N2 non-small cell lung cancer: outcomes update of North American Intergroup 0139 (RTOG 9309). J Clin Oncol 2005;23(16S):624s(abstract 7014).
5. Rusch V, Albain K, Turrisi A, Swann S, Shepherd F, Chen Y, Livingston R, Darling G, Cox J, Sause W. Phase III trial of concurrent chemotherapy and radiotherapy (CT/RT) versus CT/RT followed by surgical resection for stage IIIA-N2 non-small cell lung cancer: outcomes and implications for surgical management in North American Intergroup 0139 (RTOG 9309). Lung Cancer 2005;49(Suppl. 2):S15(abstract O-035).

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Paul E. Van Schil Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Van Schil, P. E. Search for Related Content PubMed PubMed Citation Articles by Van Schil, P. E. Related Collections Lung - cancer