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Letters to the Editor |
University of Medical Sciences Pozna
, Department of Thoracic Surgery, Szamarzewski Street 62, 60-569 Poznan, Poland
Received 10 March 2009; accepted 11 March 2009.
* Corresponding author. Tel.: +48 616654349; fax: +48 616654353. (Email: thorax{at}usoms.poznan.pl; dyszkiewicz{at}wp.pl).
Key Words: Coronary artery disease • Lung cancer • Sternotomy
We would like to thank Dr Apostolakis for his interest and insightful comments [1] regarding our paper on combined management of unstable coronary artery disease and lung cancer [2].
The main concern of the authors was the question whether sternotomy allowed for an oncologically radical resection of lung cancer in this group of patients. In our opinion, it is almost always feasible, although an obviously more challenging procedure especially on the left side. Special attention is required to avoid the excessive stress on the heart and potential graft injury. It is also reflected in our data where we had five patients with left lung cancer and in four the left thoracotomy was performed. However, we cannot agree with the opinion presented by Dr Apostolakis that sternotomy is recommended solely to the right upper lobe tumors. We strongly believe that all types of right lung resections can be safely performed through this surgical approach. Also, we did not experience any vessel control problems in the hilum during resection and no violent maneuvers to the lung were required which could increase the potential risk of lung cancer cell dissemination. Moreover, no complications related to sternal overdistension were observed. The proposed T-shaped incision, which includes the sternotomy with an extension to the anterolateral thoracotomy, is worth considering in selected patients (we used it once). However, it is associated with a more significant surgical injury and has a stronger impact on the postoperative pulmonary function. It would be interesting to see the authors’ experience of this approach.
We also do not understand the reversed sequence of the procedures proposed by our colleagues from Greece, particularly that they strongly recommend staged management of these diseases (CABG or PCI followed by lung resection). For us, there is no doubt that CABG must always precede the lung resection.
The next issue is the possibility of the radical lymphadenectomy through a sternotomy. In our opinion, the radical mediastinal lymph node dissection is relatively easy especially when the posterior wall of the pericardium is opened as reported previously [3]. The only lymph node station not accessible by sternotomy is station 8 on the left side. To elucidate the doubts, the lymphadenectomy was carried out in every patient and it was not less radical than during a standard approach.
Regarding the long-term survival rate, which was 55% at 3 years, it is difficult to draw conclusions because of the small and not homogenous groups of patients including patients with accidental N2 disease and after wedge resection of the tumor (two patients).
Finally, we strongly state that simultaneous surgical management of coronary disease and lung cancer is a reasonable and safe method of treatment. The surgical approach can vary depending on the exact location of the pathology in the lung and heart and surgeon's experience; however the sternotomy seems to be the best approach in this group of patients.
References
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