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Ann Thorac Surg 1997;64:1591-1592
© 1997 The Society of Thoracic Surgeons
DR THOMAS M. EGAN (Chapel Hill, NC): I congratulate you on a very nice study. In 1988 you described your experience with this disease. You identified groups of patients who had a relatively poor prognosis and then set about in a prospective way to evaluate a protocol that might better their outcome. It appears that you have made a substantial improvement in survival of patients with advanced thymoma.
I have a couple of questions. Particularly in patients who were treated with preoperative therapy, how comfortable are you with the accuracy of your preoperative staging? Most patients are staged at operation, and you had to devise methods to stage these patients before that to initiate preoperative neoadjuvant therapy. Your patients with advanced disease appeared to do better, and there was a reduction in deaths caused by tumor in your group III patients. Was that reduction in deaths related to the duration of follow-up, or was the recurrence-free survival substantially better in patients in group III?
Thank you for sending me the manuscript. It is very well written. This is a nice piece of work.
DR VENUTA: Thank you. Regarding your first question about preoperative staging for stage III and IV lesions, all patients with suspected stage IV lesions underwent thoracoscopy before receiving neoadjuvant chemotherapy. This is very important, and I will give an example of why. One patient was scheduled as having a stage IV tumor, but it was not a stage IV thymoma at all; in fact, the suspected pleural metastases were multiple bilateral schwannomas. Histologic confirmation of metastases is crucial in this subset of patients. In the case of stage III tumors, there are two situations in which we tend to use neoadjuvant chemotherapy: tumors that are highly infiltrative or lesions that we think we cannot resect radically before a course of neoadjuvant chemotherapy. However, all of these patients underwent anterior mediastinotomy, thoracoscopy, or both for better staging and histologic confirmation. Three patients had both procedures.
As for the incidence of tumor-related deaths, I think we have to wait a little longer before reaching definitive conclusions. In our previous series, there were 11 recurrences at a mean time of 79 months after operation. Thus, most of the lesions recurred before 8 or 9 years postoperatively. The first patient in this series underwent operation 8 years ago. However, the mean follow-up for the current series is 58 months. So we have to wait a few more years to see if we have merely delayed the onset of recurrence or if we have decreased the incidence.
DR RAYMOND A. DIETER, JR (Glen Ellyn, IL): I enjoyed this very much. We have approached these problems a number of times. You talked about multiple surgical procedures done in the past. In a number of patients, my associates and I have done a midsternotomy, then a right thoracotomy and then a left thoracotomy, in other words, staged procedures 6 or 8 weeks apart because they are so extensive. We followed with chemotherapy and irradiation. Have you had any experience with this approach to very extensive tumors when you first see them?
A problem we have encountered is that the pathologist has misinterpreted or not established a diagnosis of thymoma initially. Twenty years or more later, it recurs, and then the diagnosis is recurrent thymoma. Retrospectively it was that initially.
Last, we have seen thymomas that actually invaded the myocardium, and then a coagulopathy developed. How much of a problem with coagulopathy have you had?
DR VENUTA: Thank you for your questions and comments. We have sporadic experience with these multiple approaches in our previous series. This time, the patients received only minor surgical procedures, as I told Dr Egan. I mentioned thoracoscopy, which was unilateral, and anterior mediastinotomy for stage III lesions. I do not think this approach had an impact on the outcome of chemotherapy or the following major surgical procedure.
Our pathologist has a wide experience with tumors of the mediastinum and is pretty well known in his field. We have never had problems with the diagnosis, even when mixed histologies were present in the same lesion.
We had no problem with bleeding in these patients. It was not a complication in this series or in our previous group of patients.
Related Article
Ann. Thorac. Surg. 1997 64: 1585-1591.
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